Provider Demographics
NPI:1659839322
Name:RILEY, GARY FONTA
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:FONTA
Last Name:RILEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 OLD BAINBRIDGE RD APT 1407
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-3573
Mailing Address - Country:US
Mailing Address - Phone:850-405-5646
Mailing Address - Fax:
Practice Address - Street 1:2660 OLD BAINBRIDGE RD APT 1407
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-3573
Practice Address - Country:US
Practice Address - Phone:850-405-5646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker