Basic Information
| Provider Information | |||||||||
| NPI: | 1831624741 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FITZGIBBON | ||||||||
| FirstName: | JU-LIN | ||||||||
| MiddleName: | THAM | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | THAM | ||||||||
| OtherFirstName: | JU-LIN | ||||||||
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| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2976 MOOSE MOUNTAIN RD | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997096072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6179329723 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1717 W. COWLES STREET | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2017 | ||||||||
| LastUpdateDate: | 10/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 116469 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.