Basic Information
| Provider Information | |||||||||
| NPI: | 1326552928 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOUNTAIN | ||||||||
| FirstName: | ADAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 322 ALBANY SHAKER RD | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 122112042 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3157780554 | ||||||||
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| Practice Location | |||||||||
| Address1: | 250 PLEASANT ST | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 033017539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6032252711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2017 | ||||||||
| LastUpdateDate: | 01/18/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 119573 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 076562-21 | 01 | NH | RN LICENSE | OTHER |