Provider Demographics
NPI:1154574275
Name:FITZGERALD-GUTWEILER, KRISTIN SHEA (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SHEA
Last Name:FITZGERALD-GUTWEILER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 WICHITA ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77004-5952
Mailing Address - Country:US
Mailing Address - Phone:832-930-1078
Mailing Address - Fax:936-244-4584
Practice Address - Street 1:1805 WICHITA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77004-5952
Practice Address - Country:US
Practice Address - Phone:832-930-1078
Practice Address - Fax:936-244-4584
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05926363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB112498Medicare PIN
TXTXB112494Medicare PIN