Provider Demographics
NPI:1417315250
Name:FITZGERALD, EVAN (PTA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 OAKSHADE ST
Mailing Address - Street 2:#61
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-2173
Mailing Address - Country:US
Mailing Address - Phone:248-635-5256
Mailing Address - Fax:
Practice Address - Street 1:1505 OAKSHADE ST
Practice Address - Street 2:#61
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-2173
Practice Address - Country:US
Practice Address - Phone:248-635-5256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502004814225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant