Basic Information
| Provider Information | |||||||||
| NPI: | 1720062417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13512 W READE AVE | ||||||||
| Address2: | |||||||||
| City: | LITCHFIELD PARK | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853404019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235354372 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5702 W CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6238485000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 01/29/2016 | ||||||||
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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 | 207P00000X | 2412 | AZ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 11450 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 538192 | 05 | AZ | MEDICAID | 860373636 | 01 | AZ | HUMANA GROUP | OTHER | AW1436 | 01 | AZ | HEALTHNET GROUP | OTHER | 3981220 | 01 | AZ | EVERCARE GROUP | OTHER | 453051001 | 01 | AZ | GROUP HEALTH GROUP | OTHER |