Provider Demographics
NPI:1336499458
Name:FITZWATER, RYANE ELAINE (PA)
Entity Type:Individual
Prefix:MRS
First Name:RYANE
Middle Name:ELAINE
Last Name:FITZWATER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RYANE
Other - Middle Name:
Other - Last Name:CARDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1103 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1921
Mailing Address - Country:US
Mailing Address - Phone:573-760-8488
Mailing Address - Fax:
Practice Address - Street 1:1103 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1921
Practice Address - Country:US
Practice Address - Phone:573-760-8488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-17
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012035050363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical