Healthcare Provider Details

I. General information

NPI: 1790228013
Provider Name (Legal Business Name): BRIAN KEITH FONTENOT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2016
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 ALBERT L BICKNELL DR STE 5C
SHREVEPORT LA
71103-3943
US

IV. Provider business mailing address

2751 ALBERT L BICKNELL DR STE 5C
SHREVEPORT LA
71103-3943
US

V. Phone/Fax

Practice location:
  • Phone: 318-227-9777
  • Fax: 318-459-1188
Mailing address:
  • Phone: 318-227-9777
  • Fax: 318-459-1188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number303880
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: