Provider Demographics
NPI:1083160055
Name:FISHER, TRACY WAYNE (RD)
Entity Type:Individual
Prefix:MR
First Name:TRACY
Middle Name:WAYNE
Last Name:FISHER
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701-3840
Mailing Address - Country:US
Mailing Address - Phone:970-542-3347
Mailing Address - Fax:
Practice Address - Street 1:1000 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701-3290
Practice Address - Country:US
Practice Address - Phone:970-542-3347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-30
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered