Provider Demographics
NPI:1164044731
Name:FONTAINE, KASEY NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:KASEY
Middle Name:NICOLE
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 GENESEE AVE STE 820
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1219
Mailing Address - Country:US
Mailing Address - Phone:858-677-0777
Mailing Address - Fax:
Practice Address - Street 1:9850 GENESEE AVE STE 820
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1219
Practice Address - Country:US
Practice Address - Phone:858-677-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-17
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61270555363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2211238Medicaid