Provider Demographics
NPI:1053846774
Name:FISHER, SHAWN D (PA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:D
Last Name:FISHER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6666 BALI HAI DR.
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33437
Mailing Address - Country:US
Mailing Address - Phone:888-789-6672
Mailing Address - Fax:646-862-9066
Practice Address - Street 1:6666 BALI HAI DRIVE
Practice Address - Street 2:
Practice Address - City:BB
Practice Address - State:FL
Practice Address - Zip Code:33437
Practice Address - Country:US
Practice Address - Phone:888-789-6672
Practice Address - Fax:646-862-9066
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-01
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0053071363A00000X
FLPA9113659363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant