1730860636 NPI number — AMANDA KELLY FITZPATRICK OD

Table of content: AMANDA KELLY FITZPATRICK OD (NPI 1730860636)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730860636 NPI number — AMANDA KELLY FITZPATRICK OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZPATRICK
Provider First Name:
AMANDA
Provider Middle Name:
KELLY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1730860636
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/01/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
460TH MEDICAL GROUP, BUCKLEY AFB
Provider Second Line Business Mailing Address:
275 S. ASPEN ST
Provider Business Mailing Address City Name:
BUCKLEY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-847-6092
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 S ASPEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUCKLEY AFB
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80011-9562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
720-847-6092
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2023

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: 152W00000X , with the licence number:  009821 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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