Provider Demographics
NPI:1275623001
Name:FISHER, TIMOTHY (DPM)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 LARAMIE ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-1969
Mailing Address - Country:US
Mailing Address - Phone:307-514-9901
Mailing Address - Fax:307-275-9880
Practice Address - Street 1:4112 LARAMIE ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1969
Practice Address - Country:US
Practice Address - Phone:307-514-9901
Practice Address - Fax:307-275-9880
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332B00000X
WY113213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY121842500Medicaid
WYU79947Medicare UPIN
WY121842500Medicaid