Provider Demographics
NPI:1609357037
Name:FITZGERALD, JARED BLAINE (AA)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:BLAINE
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE POINT STE 300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4569
Practice Address - Country:US
Practice Address - Phone:864-522-3700
Practice Address - Fax:864-522-3705
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAA459367H00000X
SC67367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant