MEDICARE: CHAD RYAN FONTANA P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA02691	TX
2	363AS0400X	Surgical Physician Assistant	PA02691	TX

General Provider Information

NPI Number	:	1679533590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAD RYAN FONTANA P.A.

Provider Business Mailing Address
First Line	:	6818 AUSTIN CENTER BLVD STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78731-3100
Country	:	US
Telephone Number	:	512-856-1000
Fax Number	:

Provider Business Practice Location Address
First Line	:	6818 AUSTIN CENTER BLVD STE 200
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78731-3100
Country	:	US
Telephone Number	:	512-856-1000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2006
Last Update Date	:	12/30/2021

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