Provider Demographics
NPI:1578062907
Name:FITZPATRICK, MIA MIKEL-CORTESE (PT, DPT)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:MIKEL-CORTESE
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6010 MORNING GLEN CT
Mailing Address - Street 2:
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95765-4211
Mailing Address - Country:US
Mailing Address - Phone:916-532-2217
Mailing Address - Fax:
Practice Address - Street 1:6526 LONETREE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-5886
Practice Address - Country:US
Practice Address - Phone:916-772-2909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT294357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT294357OtherSTATE OF CA