Provider Demographics
NPI:1467461475
Name:FITZGIBBONS, GARRETT JAMES (PT)
Entity Type:Individual
Prefix:MR
First Name:GARRETT
Middle Name:JAMES
Last Name:FITZGIBBONS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4002 EXECUTIVE PARK BLVD STE 800
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9069
Mailing Address - Country:US
Mailing Address - Phone:910-477-6236
Mailing Address - Fax:910-477-6357
Practice Address - Street 1:4002 EXECUTIVE PARK BLVD STE 800
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-9069
Practice Address - Country:US
Practice Address - Phone:910-477-6236
Practice Address - Fax:910-477-6357
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP14504225100000X
MEPT3337225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080004847CT16OtherBCBS
ME432752999Medicaid