Basic Information
| Provider Information | |||||||||
| NPI: | 1669499133 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FISKE | ||||||||
| FirstName: | DWIGHT | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C, RN, AEMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 W 1ST ST | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487639688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898208127 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487639237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893623411 | ||||||||
| FaxNumber: | 9893629925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 363A00000X | 5601003088 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 542502590A | 05 | GA | MEDICAID | 01147225 | 01 | GA | AMERIGROUP | OTHER | 542502590B | 05 | GA | MEDICAID |