Provider Demographics
NPI:1902901887
Name:LAFONTANT, ANDY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANDY
Middle Name:
Last Name:LAFONTANT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:ANDREW
Other - Middle Name:
Other - Last Name:LAFONTANT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:195 14TH ST NE
Mailing Address - Street 2:SUITE 1405
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2671
Mailing Address - Country:US
Mailing Address - Phone:914-584-0541
Mailing Address - Fax:
Practice Address - Street 1:1170 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST POINT
Practice Address - State:GA
Practice Address - Zip Code:30344-3615
Practice Address - Country:US
Practice Address - Phone:404-466-1654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004404207P00000X, 363A00000X
FLPA9102384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPENDINGMedicare ID - Type Unspecified