1588179469 NPI number — MITCHELL JACOB FITZPATRICK

Table of content: MITCHELL JACOB FITZPATRICK (NPI 1588179469)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588179469 NPI number — MITCHELL JACOB FITZPATRICK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZPATRICK
Provider First Name:
MITCHELL
Provider Middle Name:
JACOB
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588179469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7100 E WOLF LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASILLA
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99654-9314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16941 N EAGLE RIVER LOOP RD STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAGLE RIVER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99577-7824
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-726-5330
Provider Business Practice Location Address Fax Number:
907-726-5366
Provider Enumeration Date:
12/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00002943 . This is a "TRICARE" identifier , issued by the state of ( AK ) . This identifiers is of the category "OTHER".




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