Provider Demographics
NPI:1750320586
Name:FITZGERALD, KIMBERLY I
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:
Last Name:FITZGERALD
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:FITZGERALD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:29 EXETER ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02170-1322
Mailing Address - Country:US
Mailing Address - Phone:617-276-7573
Mailing Address - Fax:
Practice Address - Street 1:59 ORNAC
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:MA
Practice Address - Zip Code:01742-3317
Practice Address - Country:US
Practice Address - Phone:978-369-5391
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1682363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical