Provider Demographics
NPI:1912459892
Name:FONTAN, GABRIEL
Entity Type:Individual
Prefix:
First Name:GABRIEL
Middle Name:
Last Name:FONTAN
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 1:9816 BOMARC ST
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79924-4904
Mailing Address - Country:US
Mailing Address - Phone:915-503-3052
Mailing Address - Fax:
Practice Address - Street 1:9816 BOMARC ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79924-4904
Practice Address - Country:US
Practice Address - Phone:915-503-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-26
Last Update Date:2016-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician