Provider Demographics
NPI:1154524874
Name:FITZGIBBON, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:FITZGIBBON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-7582
Mailing Address - Country:US
Mailing Address - Phone:415-420-6127
Mailing Address - Fax:707-584-4814
Practice Address - Street 1:1331 MEDICAL CENTER DR STE A
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2900
Practice Address - Country:US
Practice Address - Phone:707-584-3433
Practice Address - Fax:707-584-4814
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist