Provider Demographics
NPI:1609590389
Name:FITZGERALD, JOHN BRYCE (APRN, AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:BRYCE
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:APRN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 DUTCHMANS LN STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4710
Mailing Address - Country:US
Mailing Address - Phone:502-897-1794
Mailing Address - Fax:502-897-3852
Practice Address - Street 1:3605 NORTHGATE CT
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6400
Practice Address - Country:US
Practice Address - Phone:812-920-0408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28207179C363LA2100X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100861520Medicaid
KYK4121802OtherMEDICARE
ININ1920035OtherMEDICARE