Provider Demographics
NPI:1093586281
Name:FISHER, MICHAEL SHAUN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SHAUN
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR
Mailing Address - State:MO
Mailing Address - Zip Code:63077-2018
Mailing Address - Country:US
Mailing Address - Phone:636-358-3019
Mailing Address - Fax:
Practice Address - Street 1:1335 REDWOOD DR
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-2018
Practice Address - Country:US
Practice Address - Phone:636-358-3019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications