Healthcare Provider Details

I. General information

NPI: 1063411189
Provider Name (Legal Business Name): ROBERT A WITT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 9TH AVE
BELLE PLAINE IA
52208-2200
US

IV. Provider business mailing address

105 9TH AVE
BELLE PLAINE IA
52208-2200
US

V. Phone/Fax

Practice location:
  • Phone: 319-444-3210
  • Fax: 319-444-4099
Mailing address:
  • Phone: 319-444-3210
  • Fax: 319-444-4099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000694
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: