Provider Demographics
NPI:1043218282
Name:FISHER, JONATHAN (PA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:85 BROAD ST LBBY LEVEL
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10004-2434
Mailing Address - Country:US
Mailing Address - Phone:212-357-4420
Mailing Address - Fax:212-357-4922
Practice Address - Street 1:85 BROAD STREET, LOBBY LEVEL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10004
Practice Address - Country:US
Practice Address - Phone:212-357-4420
Practice Address - Fax:212-357-4922
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO522328Medicare ID - Type Unspecified