Provider Demographics
NPI:1881782225
Name:FITZPATRICK, DEMARIS A (PA)
Entity type:Individual
Prefix:
First Name:DEMARIS
Middle Name:A
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-857-5650
Mailing Address - Fax:701-857-5031
Practice Address - Street 1:111 W 1ST STREET
Practice Address - Street 2:
Practice Address - City:VELVA
Practice Address - State:ND
Practice Address - Zip Code:58790
Practice Address - Country:US
Practice Address - Phone:701-338-2066
Practice Address - Fax:701-338-2048
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0160363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11058Medicaid
ND24339Medicare ID - Type Unspecified
ND11058Medicaid