Basic Information
| Provider Information | |||||||||
| NPI: | 1285202317 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | JOHN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6077 PRIMACY PKWY STE 140 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381195754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016413000 | ||||||||
| FaxNumber: | 9017012400 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 CONCOURSE AVE STE 363 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381042023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012606161 | ||||||||
| FaxNumber: | 9012606162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2021 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 4659 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | T20290A | 01 | TN | TN MEDICARE | OTHER |