Healthcare Provider Details

I. General information

NPI: 1275582751
Provider Name (Legal Business Name): PAUL S FONTANA ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 04/18/2024
Certification Date: 04/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W IRONWOOD DR STE 320
COEUR D ALENE ID
83814-4485
US

IV. Provider business mailing address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5250
  • Fax: 208-625-5251
Mailing address:
  • Phone: 208-625-5250
  • Fax: 208-625-5251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberN34935
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN00161870
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP30007150
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP733A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: