Provider Demographics
NPI:1528116662
Name:FITZWATER, LARRY L (PA-C)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:L
Last Name:FITZWATER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#1 HEALTHCARE DRIVE
Mailing Address - Street 2:
Mailing Address - City:PHILIPPI
Mailing Address - State:WV
Mailing Address - Zip Code:26416
Mailing Address - Country:US
Mailing Address - Phone:304-457-1760
Mailing Address - Fax:304-457-1516
Practice Address - Street 1:#1 HEALTHCARE DRIVE
Practice Address - Street 2:
Practice Address - City:PHILIPPI
Practice Address - State:WV
Practice Address - Zip Code:26416
Practice Address - Country:US
Practice Address - Phone:304-457-1760
Practice Address - Fax:304-457-1516
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV318363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV318OtherLICENSE