Provider Demographics
NPI:1508524018
Name:FRITZ, KENTON (PA)
Entity Type:Individual
Prefix:MR
First Name:KENTON
Middle Name:
Last Name:FRITZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-9624
Mailing Address - Country:US
Mailing Address - Phone:360-388-2623
Mailing Address - Fax:
Practice Address - Street 1:120 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-9624
Practice Address - Country:US
Practice Address - Phone:360-388-2623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61237810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant