Provider Demographics
NPI:1104045582
Name:FISHER, SUZETTE MARIE (EDS)
Entity Type:Individual
Prefix:
First Name:SUZETTE
Middle Name:MARIE
Last Name:FISHER
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22119 N PEDREGOSA DR
Mailing Address - Street 2:
Mailing Address - City:SUN CITY WEST
Mailing Address - State:AZ
Mailing Address - Zip Code:85375-2695
Mailing Address - Country:US
Mailing Address - Phone:623-476-7005
Mailing Address - Fax:
Practice Address - Street 1:15802 N. PARKVIEW PLACE
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374
Practice Address - Country:US
Practice Address - Phone:623-876-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ889305Medicaid