Provider Demographics
NPI:1417281171
Name:FITCH, MATTHEW FREMONT (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:FREMONT
Last Name:FITCH
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 1:1901 JUAN TABO BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3303
Mailing Address - Country:US
Mailing Address - Phone:505-262-9200
Mailing Address - Fax:505-262-9201
Practice Address - Street 1:1901 JUAN TABO BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-3303
Practice Address - Country:US
Practice Address - Phone:505-262-9200
Practice Address - Fax:505-262-9201
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0027363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant