Basic Information
| Provider Information | |||||||||
| NPI: | 1841234630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISH | ||||||||
| FirstName: | IRWIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 S SPORTING HILL RD | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170503058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179431781 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 107 S SPORTING HILL RD | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170503058 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7179431781 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA002426L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | C50000117 | DE | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0001120143 | 05 | DE | MEDICAID |