Basic Information
| Provider Information | |||||||||
| NPI: | 1073522397 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | ETHAN | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 NORTH CENTER ST | ||||||||
| Address2: | #800 | ||||||||
| City: | LEHI | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840437406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019901911 | ||||||||
| FaxNumber: | 8019901912 | ||||||||
| Practice Location | |||||||||
| Address1: | 5121 S COTTONWOOD STREET | ||||||||
| Address2: | INTERMOUNTAIN MEDICAL CENTER | ||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015075248 | ||||||||
| FaxNumber: | 8017335618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2006 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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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 | 207L00000X | 96-323265-1205 | UT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100501227 | 05 | ID | MEDICAID | PRA04837 | 01 | UT | MOLINA | OTHER | 1502954 | 01 | UT | UMWA | OTHER | 8597445 | 01 | UT | WORKERS COMP FUND | OTHER | 112422600 | 05 | WY | MEDICAID | 40044 | 01 | UT | PEHP | OTHER | 27753 | 01 | UT | HEALTHY U | OTHER | 805478500 | 05 | ID | MEDICAID | 870545614FI2 | 01 | UT | EDUCATORS MUTUAL | OTHER | 281279 | 01 | UT | DMBA | OTHER | 2090168 | 01 | UT | UNITED HEALTHCARE | OTHER | QM0000075886 | 01 | UT | ALTIUS | OTHER | 107007882102 | 01 | UT | IHC | OTHER | 820721 | 05 | AZ | MEDICAID |