Provider Demographics
NPI:1639925340
Name:FITZWATER, SCOTT ANDREW (PTA)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ANDREW
Last Name:FITZWATER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1784 IRA DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-5441
Mailing Address - Country:US
Mailing Address - Phone:505-231-3408
Mailing Address - Fax:
Practice Address - Street 1:700 HIGH ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2565
Practice Address - Country:US
Practice Address - Phone:505-242-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPTA1597225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant