Basic Information
| Provider Information | |||||||||
| NPI: | 1710229737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONTENOT | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | SR. | ||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1407 UNION AVE STE 640 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668360 | ||||||||
| FaxNumber: | 9013022360 | ||||||||
| Practice Location | |||||||||
| Address1: | 877 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9015458699 | ||||||||
| FaxNumber: | 9015458996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2013 | ||||||||
| LastUpdateDate: | 08/11/2014 | ||||||||
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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 | 17580 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 02636357 | 05 | MS | MEDICAID | 197571001 | 05 | AR | MEDICAID | Q002094 | 05 | TN | MEDICAID |