Basic Information
| Provider Information | |||||||||
| NPI: | 1407806573 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONTAINE | ||||||||
| FirstName: | ALPHONSO | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 850001 | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328850254 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277245600 | ||||||||
| FaxNumber: | 7277245689 | ||||||||
| Practice Location | |||||||||
| Address1: | 2250 DREW ST | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337653305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277245600 | ||||||||
| FaxNumber: | 7277245689 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 02/09/2010 | ||||||||
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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 | 363AM0700X | PA00002737 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.