Basic Information
| Provider Information | |||||||||
| NPI: | 1437447158 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FONTANARES | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5544 GREENWICH RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234626563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574660089 | ||||||||
| FaxNumber: | 7574668017 | ||||||||
| Practice Location | |||||||||
| Address1: | 5544 GREENWICH RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234626563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574660089 | ||||||||
| FaxNumber: | 7574668017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2011 | ||||||||
| LastUpdateDate: | 02/07/2014 | ||||||||
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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 | 363A00000X | 0110003637 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 493396 | 01 | VA | BCBSVA | OTHER | 10106950P | 01 | VA | SENTARA HEALTH PLAN | OTHER | P01196732 | 01 | VA | RAILROAD MEDICARE | OTHER | 1437447158 | 05 | VA | MEDICAID | 179CG | 01 | NC | BCBSNC | OTHER | 10106950P | 01 | VA | OPTIMA HEALTH PLAN | OTHER |