Healthcare Provider Details

I. General information

NPI: 1972588044
Provider Name (Legal Business Name): AMANDA KRISTINE FITZWATER DUTTON M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA KRISTINE FITZWATER M.D.

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 KEMPER RD
ARLINGTON VA
22206-2315
US

IV. Provider business mailing address

11995 SINGLETREE LN SUITE 500
EDEN PRAIRIE MN
55344-5347
US

V. Phone/Fax

Practice location:
  • Phone: 952-595-1100
  • Fax: 612-294-4903
Mailing address:
  • Phone: 952-595-1301
  • Fax: 612-294-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number22499
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2006038229
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101240874
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number042-0011239
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: