Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0203X | Pediatric Critical Care Doctor | 11709353-1204 | UT |
NPI | 1174056758 |
---|---|
Provider Name | Andrew Daniel Fontes |
First Address | Salt Lake City, UT 84108-1287 |
Second Address | Salt Lake City, UT 84108-1287 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2017 |
Last Update Date | 05/06/2020 |