Healthcare Provider Details

I. General information

NPI: 1417281171
Provider Name (Legal Business Name): MATTHEW FREMONT FITCH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2009
Last Update Date: 12/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 JUAN TABO BLVD NE
ALBUQUERQUE NM
87112-3303
US

IV. Provider business mailing address

1901 JUAN TABO BLVD NE
ALBUQUERQUE NM
87112-3303
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-9200
  • Fax: 505-262-9201
Mailing address:
  • Phone: 505-262-9200
  • Fax: 505-262-9201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2009-0027
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: