Provider Demographics
NPI:1275550709
Name:FITZSIMMONS, RICHARD (RNFNP)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:FITZSIMMONS
Suffix:
Gender:M
Credentials:RNFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 WEST ATEN ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9805
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:125 SOUTH 5TH ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227
Practice Address - Country:US
Practice Address - Phone:760-344-8100
Practice Address - Fax:760-344-2628
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN421408363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPPIN9393Medicaid
CAGR006315OtherGROUP MEDI-CAL #
CAW13536COtherGROUP MEDICARE #
CAWNP9393COtherMEDICARE PTAN
CAWNP9393CMedicare PIN
CAPPIN9393Medicaid