Basic Information
| Provider Information | |||||||||
| NPI: | 1144215153 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 670 | ||||||||
| Address2: | |||||||||
| City: | HUNTERTOWN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467480670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607483650 | ||||||||
| FaxNumber: | 2607483651 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 MAGNAVOX WAY | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468041537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607483650 | ||||||||
| FaxNumber: | 3607483651 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 02/04/2019 | ||||||||
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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 | 363AM0700X | 10000311A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 300006102 | 05 | IN | MEDICAID | 931711 | 01 | IN | BCBS | OTHER |