Provider Demographics
NPI:1275550709
Name:FITZSIMMONS, RICHARD (FNP)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:
Last Name:FITZSIMMONS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 WEST ATEN ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9805
Mailing Address - Country:US
Mailing Address - Phone:760-355-7731
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:1550 SOUTH IMPERIAL AVENUE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243
Practice Address - Country:US
Practice Address - Phone:760-339-2802
Practice Address - Fax:760-355-9520
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN421408363L00000X
CA9393363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWNP9393COtherMEDICARE PTAN
CAPPIN9393Medicaid
CAGR006315OtherGROUP MEDI-CAL #
CAW13536COtherGROUP MEDICARE #
CAWNP9393CMedicare PIN
CAPPIN9393Medicaid