Provider Demographics
NPI:1659340032
Name:FITZGIBBON, JAMES G (PA C)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:G
Last Name:FITZGIBBON
Suffix:
Gender:M
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 1:1010 N WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53548-1561
Mailing Address - Country:US
Mailing Address - Phone:608-741-3800
Mailing Address - Fax:
Practice Address - Street 1:1010 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-1561
Practice Address - Country:US
Practice Address - Phone:608-741-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1054363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42975200Medicaid
041A15875Medicare ID - Type Unspecified
S88967Medicare UPIN