Basic Information
| Provider Information | |||||||||
| NPI: | 1083615447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | LYNN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1010 N KANSAS ST STE 3001D | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162932607 | ||||||||
| FaxNumber: | 3162932696 | ||||||||
| Practice Location | |||||||||
| Address1: | 1010 N KANSAS ST STE 3001D | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672143124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3162932607 | ||||||||
| FaxNumber: | 3162932696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 04-30818 | KS | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 105275 | 01 | KS | BC/BS INDIVIDUAL | OTHER | 111215 | 01 | KS | BC/BS GROUP | OTHER | 200269400C | 05 | KS | MEDICAID | 460593 | 01 | KS | CHILDREN'S MERCY FAMILY H | OTHER |