Basic Information
| Provider Information | |||||||||
| NPI: | 1003156498 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PATALINGHUG | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | FONTILLAS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJP - PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322314008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443199 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 W 8TH ST | ||||||||
| Address2: | UFJAX - DEPT. OF ANESTHESIOLOGY | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322096511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042444195 | ||||||||
| FaxNumber: | 9042444908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2013 | ||||||||
| LastUpdateDate: | 07/14/2015 | ||||||||
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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 | ARNP3318112 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 003131804B | 05 | GA | MEDICAID | 008339000 | 05 | FL | MEDICAID |