Provider Demographics
NPI:1366493959
Name:FISH, STEPHEN M (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:FISH
Suffix:
Gender:M
Credentials:MD
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 969
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-0969
Mailing Address - Country:US
Mailing Address - Phone:425-888-5511
Mailing Address - Fax:425-888-5513
Practice Address - Street 1:404 MAIN AVE S
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98045-8215
Practice Address - Country:US
Practice Address - Phone:425-888-5511
Practice Address - Fax:425-888-5513
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8TA009OtherTRAILBLAZER MEDICARE FIRST LOCATION
WA1042852Medicaid
WA8TA098OtherTRAILBLAZER MEDICARE SECOND LOCATION
WAE17375Medicare UPIN