Healthcare Provider Details

I. General information

NPI: 1548671472
Provider Name (Legal Business Name): KATIE FOUNTAIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATIE DIANA FOUNTAIN

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 03/18/2026
Certification Date: 03/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 EMBARCADERO CTR LBBY LEVEL
SAN FRANCISCO CA
94111-3823
US

IV. Provider business mailing address

1 EMBARCADERO CTR STE 1900
SAN FRANCISCO CA
94111-3723
US

V. Phone/Fax

Practice location:
  • Phone: 888-663-6331
  • Fax: 415-252-7176
Mailing address:
  • Phone: 888-663-6331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9121303
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08451
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007228
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.1620
License Number StateAL
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6001
License Number StateSC
# 6
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number67837
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: