Basic Information
| Provider Information | |||||||||
| NPI: | 1770524977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZWATER | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | H. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 MORRIS ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043887782 | ||||||||
| FaxNumber: | 3043887788 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 WASHINGTON ST E | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 253011834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043881965 | ||||||||
| FaxNumber: | 3043881969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 04/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 2253 | WV | N | Allopathic & Osteopathic Physicians | General Practice | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 208800000X | 2253 | WV | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.