Provider Demographics
NPI:1336328657
Name:FONTENOT, HEATHER MICHELLE (LSA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:MICHELLE
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 FARM TO MARKET ROAD 1826 BLDG 2
Mailing Address - Street 2:SUITE 206
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78737
Mailing Address - Country:US
Mailing Address - Phone:512-288-8200
Mailing Address - Fax:512-288-8207
Practice Address - Street 1:7900 FM 1826 BLDG 2
Practice Address - Street 2:SUITE 206
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78737-1407
Practice Address - Country:US
Practice Address - Phone:512-288-8200
Practice Address - Fax:521-288-8207
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-02
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX107080246ZC0007X
TXSA00401246ZC0007X, 246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXSA00401OtherLSA IDENTIFICATION NUMBER