Provider Demographics
NPI:1083171029
Name:FISHER, PATRICK (PA)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 STRATFORD RD UPPR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-1803
Mailing Address - Country:US
Mailing Address - Phone:716-697-4301
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY023425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program