Provider Demographics
NPI:1548565682
Name:FITZGERALD, KEVIN BARRY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:BARRY
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 1:38555 ST. JOHN, CIR.
Mailing Address - Street 2:PO BOX 1068
Mailing Address - City:TALKEETNA
Mailing Address - State:AK
Mailing Address - Zip Code:99676
Mailing Address - Country:US
Mailing Address - Phone:907-733-2704
Mailing Address - Fax:907-733-2705
Practice Address - Street 1:915 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:TIETON
Practice Address - State:WA
Practice Address - Zip Code:98947-9802
Practice Address - Country:US
Practice Address - Phone:509-673-0044
Practice Address - Fax:509-673-0054
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2104363AM0700X
WAPA60427970363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2040154Medicaid
WA0419110OtherLABOR AND INDUSTRIES