Provider Demographics
NPI:1790228013
Name:FONTENOT, BRIAN KEITH (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:FONTENOT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2751 ALBERT L BICKNELL DR STE 5C
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3943
Mailing Address - Country:US
Mailing Address - Phone:318-227-9777
Mailing Address - Fax:318-459-1188
Practice Address - Street 1:2751 ALBERT L BICKNELL DR STE 5C
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-3943
Practice Address - Country:US
Practice Address - Phone:318-227-9777
Practice Address - Fax:318-459-1188
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA303880363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical