Provider Demographics
NPI:1114953155
Name:FIZZARD, STEPHANIE QUILIANNA (PA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:QUILIANNA
Last Name:FIZZARD
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 1:25902 TIPPERARY LN
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-8059
Mailing Address - Country:US
Mailing Address - Phone:949-916-2924
Mailing Address - Fax:
Practice Address - Street 1:25902 TIPPERARY LN
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-8059
Practice Address - Country:US
Practice Address - Phone:949-916-2924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA14810AMedicare PIN