Provider Demographics
NPI:1588179469
Name:FITZPATRICK, MITCHELL JACOB
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:JACOB
Last Name:FITZPATRICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 E WOLF LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-9314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16941 N EAGLE RIVER LOOP RD STE 3
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7824
Practice Address - Country:US
Practice Address - Phone:907-726-5330
Practice Address - Fax:907-726-5366
Is Sole Proprietor?:No
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK00002943OtherTRICARE