Provider Demographics
NPI:1871524199
Name:PETERSON FONTENOT, PATRICIA L (DO)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:PETERSON FONTENOT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 S COLLINS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-4643
Mailing Address - Country:US
Mailing Address - Phone:972-663-5780
Mailing Address - Fax:972-663-5785
Practice Address - Street 1:341 WHEATFIELD DR STE 190
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-4639
Practice Address - Country:US
Practice Address - Phone:469-436-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX091992004Medicaid
TX179201201Medicaid
TX091992004Medicaid
TX8L7160Medicare PIN
TXG01267Medicare UPIN