Provider Demographics
NPI:1831624741
Name:FITZGIBBON, JU-LIN THAM (PA-C)
Entity type:Individual
Prefix:
First Name:JU-LIN
Middle Name:THAM
Last Name:FITZGIBBON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JU-LIN
Other - Middle Name:
Other - Last Name:THAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2976 MOOSE MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-6072
Mailing Address - Country:US
Mailing Address - Phone:617-932-9723
Mailing Address - Fax:
Practice Address - Street 1:1717 W. COWLES STREET
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-451-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-28
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK116469363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant