Provider Demographics
NPI:1912659376
Name:FONTENOT, ABBY CAMILLE (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:CAMILLE
Last Name:FONTENOT
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 JUNIUS ST STE 500
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3900 JUNIUS ST STE 500
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1621
Practice Address - Country:US
Practice Address - Phone:469-800-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA15315363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant