Provider Demographics
NPI:1457978611
Name:FOUNTAIN, DAVID IMMANUEL FREEMAN (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:IMMANUEL FREEMAN
Last Name:FOUNTAIN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1799
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87499-1799
Mailing Address - Country:US
Mailing Address - Phone:505-564-6890
Mailing Address - Fax:
Practice Address - Street 1:1005 WATERFALL LN
Practice Address - Street 2:
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-3741
Practice Address - Country:US
Practice Address - Phone:970-749-9113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-02
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMPA2021-0009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program