Provider Demographics
NPI:1811907819
Name:FITZGERALD, TIMOTHY SHAWN (PA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:SHAWN
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1202 MEDICAL CENTER DR STE 350
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-617-6705
Mailing Address - Fax:910-431-4048
Practice Address - Street 1:1717 SHIPYARD BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-8023
Practice Address - Country:US
Practice Address - Phone:910-799-0110
Practice Address - Fax:910-799-1958
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC112679363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8930772Medicaid
NC047501023OtherTRICARE
NCP00023289OtherRAILROAD MEDICARE
NC0197953OtherCIGNA
NC0928879OtherUNITED HEALTHCARE
NC561926376OtherWORKMANS COMP
NC30772OtherBCBS OF NC
NC8930772Medicaid
NC047501023OtherTRICARE