Provider Demographics
NPI:1386719375
Name:FITZGERALD, MICHAEL T (APRN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 NICHOLASVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1428
Mailing Address - Country:US
Mailing Address - Phone:859-252-6500
Mailing Address - Fax:859-252-3073
Practice Address - Street 1:1721 NICHOLASVILLE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1428
Practice Address - Country:US
Practice Address - Phone:859-252-6500
Practice Address - Fax:859-252-3073
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14346363LF0000X, 363LA2200X, 363LG0600X
KY3006886363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0169Medicare PIN
KYK031231Medicare PIN
P70210Medicare UPIN