Healthcare Provider Details

I. General information

NPI: 1114158565
Provider Name (Legal Business Name): GEORGE LAWRENCE FICHTER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4075 COPPER RIDGE DR
TRAVERSE CITY MI
49684-7059
US

IV. Provider business mailing address

1107 FRANKLIN ST
WILLIAMSPORT PA
17701-2312
US

V. Phone/Fax

Practice location:
  • Phone: 888-632-0545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA053990
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA002381
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: