Provider Demographics
NPI:1245235761
Name:FISHER, DOUGLAS (PAC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 273
Mailing Address - Street 2:
Mailing Address - City:EAST MARION
Mailing Address - State:NY
Mailing Address - Zip Code:11939
Mailing Address - Country:US
Mailing Address - Phone:631-287-8600
Mailing Address - Fax:
Practice Address - Street 1:117 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-4923
Practice Address - Country:US
Practice Address - Phone:631-287-8600
Practice Address - Fax:631-204-1585
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00256363AM0700X
NY23-013281363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI30584OtherBLUE SHIELD
RI30584OtherBLUE SHIELD
RIP31522Medicare UPIN
MF0683391OtherDEA