1750876090 NPI number — REBECCA JO FISHER PA-C

Table of content: REBECCA JO FISHER PA-C (NPI 1750876090)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750876090 NPI number — REBECCA JO FISHER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FISHER
Provider First Name:
REBECCA
Provider Middle Name:
JO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

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:
1750876090
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
38135 MARKET SQ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ZEPHYRHILLS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33542-7505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-567-0188
Provider Business Mailing Address Fax Number:
813-355-5101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2352 BRUCE B DOWNS BLVD STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESLEY CHAPEL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-979-0440
Provider Business Practice Location Address Fax Number:
813-355-5054
Provider Enumeration Date:
06/28/2018

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: 363AS0400X , with the licence number:  PA9111299 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100867500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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