Provider Demographics
NPI:1538929088
Name:FITZGERALD, BRYAN COREY
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:COREY
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 1:4635 SUMMERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-9117
Mailing Address - Country:US
Mailing Address - Phone:704-993-8935
Mailing Address - Fax:
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-446-7934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program