Provider Demographics
NPI:1043738461
Name:FITZGERALD, NATHAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
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 1:22301 W ALSOP RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-5023
Mailing Address - Country:US
Mailing Address - Phone:907-864-8284
Mailing Address - Fax:
Practice Address - Street 1:22301 W ALSOP RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-5023
Practice Address - Country:US
Practice Address - Phone:907-864-8284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-06
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK123843363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1677181Medicaid