Basic Information
| Provider Information | |||||||||
| NPI: | 1225269459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTENO | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | MARAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033787526 | ||||||||
| FaxNumber: | 5035854278 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033787526 | ||||||||
| FaxNumber: | 5035854278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2009 | ||||||||
| LastUpdateDate: | 08/11/2009 | ||||||||
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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 | 363A00000X | PA130055 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.