Provider Demographics
NPI:1033303607
Name:FISHER-WIKOFF, TRIWANNA LASHAWN (MD)
Entity Type:Individual
Prefix:
First Name:TRIWANNA
Middle Name:LASHAWN
Last Name:FISHER-WIKOFF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRIWANNA
Other - Middle Name:LASHAWN
Other - Last Name:FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8400
Mailing Address - Fax:
Practice Address - Street 1:7201 HAWKINS VIEW DR STE 151
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3934
Practice Address - Country:US
Practice Address - Phone:817-263-7200
Practice Address - Fax:817-377-6558
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7183207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BR061OtherBCBS
TX196876001Medicaid
TX196876003Medicaid
TX196876005Medicaid
TX196876002Medicaid
TX8CD482OtherBCBS
TX8F9780Medicare PIN
TX196876003Medicaid
TX196876005Medicaid
TX196876002Medicaid