Provider Demographics
NPI:1902148885
Name:FONTAN, FERMIN MIGUEL (MD)
Entity Type:Individual
Prefix:
First Name:FERMIN
Middle Name:MIGUEL
Last Name:FONTAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 S TRIVIZ DR STE G
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-0601
Mailing Address - Country:US
Mailing Address - Phone:443-857-1115
Mailing Address - Fax:
Practice Address - Street 1:2100 S TRIVIZ DR STE G
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-0601
Practice Address - Country:US
Practice Address - Phone:443-857-1115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-0043208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery