1720062417 NPI number — MR. LANCE STEVEN FISHER PA

Table of content: MR. LANCE STEVEN FISHER PA (NPI 1720062417)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720062417 NPI number — MR. LANCE STEVEN FISHER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FISHER
Provider First Name:
LANCE
Provider Middle Name:
STEVEN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720062417
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/29/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13512 W READE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITCHFIELD PARK
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85340-4019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-535-4372
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5702 W CAMPBELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-848-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  2412 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: 11450 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 538192 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 860373636 . This is a "HUMANA GROUP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: AW1436 . This is a "HEALTHNET GROUP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 3981220 . This is a "EVERCARE GROUP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 453051001 . This is a "GROUP HEALTH GROUP" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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