Basic Information
| Provider Information | |||||||||
| NPI: | 1346234788 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTAINE | ||||||||
| FirstName: | ANNETTE | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FONTAINE | ||||||||
| OtherFirstName: | ANNETTE | ||||||||
| OtherMiddleName: | CAMPBELL | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4901 LANG AVE NE | ||||||||
| Address2: | NEW MEXICO ONCOLOGY & HEMATOLOGY CONSULTANTS, LTD | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058428171 | ||||||||
| FaxNumber: | 5052460684 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 LANG AVE NE | ||||||||
| Address2: | NEW MEXICO ONCOLOGY & HEMATOLOGY CONSULTANTS, LTD | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058428171 | ||||||||
| FaxNumber: | 5052460684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | 2005-0639 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207R00000X | 2005-0639 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 23481781 | 05 | NM | MEDICAID | BC9001772 | 01 | DEA | OTHER |