Provider Demographics
NPI:1083252530
Name:FISHER, SHANNON (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:FISHER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:
Other - Last Name:LIEWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:912 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:GRANT
Mailing Address - State:NE
Mailing Address - Zip Code:69140-3099
Mailing Address - Country:US
Mailing Address - Phone:308-352-7100
Mailing Address - Fax:
Practice Address - Street 1:912 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:GRANT
Practice Address - State:NE
Practice Address - Zip Code:69140-3099
Practice Address - Country:US
Practice Address - Phone:308-352-7100
Practice Address - Fax:308-352-7103
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2470363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant