Provider Demographics
NPI:1114008653
Name:FISHER, MARK RENARD (RPT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:RENARD
Last Name:FISHER
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1321 COLLEGE ST STE D
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4706
Mailing Address - Country:US
Mailing Address - Phone:530-662-0378
Mailing Address - Fax:530-662-9093
Practice Address - Street 1:1321 COLLEGE ST STE D
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4706
Practice Address - Country:US
Practice Address - Phone:530-662-0378
Practice Address - Fax:530-662-9093
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT228610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist