=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922780162
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AIDAN FITZGERALD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 09/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 921 S 8TH AVE STOP 8253
-----------------------------------------------------
City | POCATELLO
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83209-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-282-4726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 BLAKE ST
-----------------------------------------------------
City | HELENA
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59601-4373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-422-3154
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------