Provider Demographics
NPI:1568915791
Name:FITZGERALD, AUDREY L (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:L
Last Name:FITZGERALD
Suffix:
Gender:F
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 1:661 E ALTAMONTE DR STE 231
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5102
Mailing Address - Country:US
Mailing Address - Phone:407-303-5214
Mailing Address - Fax:407-303-5215
Practice Address - Street 1:4106 W LAKE MARY BLVD STE 212
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3344
Practice Address - Country:US
Practice Address - Phone:407-333-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-23
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109822363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant