Provider Demographics
NPI:1518572148
Name:FISHER, MARQUS ELLERY (PT, MSM)
Entity Type:Individual
Prefix:
First Name:MARQUS
Middle Name:ELLERY
Last Name:FISHER
Suffix:
Gender:M
Credentials:PT, MSM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3985 NW COLONIAL GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-4857
Mailing Address - Country:US
Mailing Address - Phone:305-458-5073
Mailing Address - Fax:
Practice Address - Street 1:289 SW STONEGATE TER STE 101
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-3457
Practice Address - Country:US
Practice Address - Phone:386-401-4309
Practice Address - Fax:386-400-5109
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT6706208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation