Provider Demographics
NPI:1689029241
Name:FITZGERALD, GORDON SCOTT
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:SCOTT
Last Name:FITZGERALD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 S 800 W
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-2400
Mailing Address - Country:US
Mailing Address - Phone:435-723-8548
Mailing Address - Fax:
Practice Address - Street 1:8606 N 11600 W
Practice Address - Street 2:
Practice Address - City:THATCHER
Practice Address - State:UT
Practice Address - Zip Code:84337-9103
Practice Address - Country:US
Practice Address - Phone:435-723-8548
Practice Address - Fax:435-239-8732
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker