Healthcare Provider Details

I. General information

NPI: 1063417756
Provider Name (Legal Business Name): TIMOTHY J FITCH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2005
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 S WILLARD ST
COTTONWOOD AZ
86326-6743
US

IV. Provider business mailing address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-649-7960
  • Fax: 928-634-1117
Mailing address:
  • Phone: 928-214-2922
  • Fax: 928-214-2932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6076
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: