Healthcare Provider Details

I. General information

NPI: 1477090900
Provider Name (Legal Business Name): RENEE MARIE FRITZ-INGALLS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: RENEE MARIE FRITZ PA

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1348 WALTON WAY STE 5700
AUGUSTA GA
30901
US

IV. Provider business mailing address

PO BOX 1705
AUGUSTA GA
30903-1705
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-8242
  • Fax: 706-722-8351
Mailing address:
  • Phone: 706-774-7263
  • Fax: 706-774-7230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0010-07002
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number009113
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: