Healthcare Provider Details

I. General information

NPI: 1710229737
Provider Name (Legal Business Name): ANDREW FONTENOT SR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 JEFFERSON AVE
MEMPHIS TN
38103-2807
US

IV. Provider business mailing address

1407 UNION AVE STE 640
MEMPHIS TN
38104-3666
US

V. Phone/Fax

Practice location:
  • Phone: 901-545-8699
  • Fax: 901-545-8996
Mailing address:
  • Phone: 901-866-8360
  • Fax: 901-302-2360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number17580
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: