Basic Information
| Provider Information | |||||||||
| NPI: | 1023430550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTENOT | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | KYLE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650865 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752650865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722331999 | ||||||||
| FaxNumber: | 9722333666 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 CITYWEST BLVD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770422300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136204000 | ||||||||
| FaxNumber: | 7134584229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2014 | ||||||||
| LastUpdateDate: | 10/09/2017 | ||||||||
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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 | 731520 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 215086402 | 05 | TX | MEDICAID | 329737602 | 05 | TX | MEDICAID | 329737601 | 05 | TX | MEDICAID | 8493UH | 01 | TX | BCBS | OTHER | P01441249 | 01 | TX | RR MEDICARE | OTHER |