Basic Information
| Provider Information | |||||||||
| NPI: | 1881782225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZPATRICK | ||||||||
| FirstName: | DEMARIS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5010 | ||||||||
| Address2: | |||||||||
| City: | MINOT | ||||||||
| State: | ND | ||||||||
| PostalCode: | 587025010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7018575650 | ||||||||
| FaxNumber: | 7018575031 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 W 1ST STREET | ||||||||
| Address2: | |||||||||
| City: | VELVA | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013382066 | ||||||||
| FaxNumber: | 7013382048 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PAC0160 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 11058 | 05 | ND | MEDICAID |