Healthcare Provider Details

I. General information

NPI: 1639925340
Provider Name (Legal Business Name): SCOTT ANDREW FITZWATER PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HIGH ST NE
ALBUQUERQUE NM
87102-2565
US

IV. Provider business mailing address

1784 IRA DR NE
RIO RANCHO NM
87144-5441
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4444
  • Fax:
Mailing address:
  • Phone: 505-231-3408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1597
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: