Provider Demographics
NPI:1548218779
Name:FISH, SUSAN H (PA-C)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:H
Last Name:FISH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11019 CANYON RD E
Mailing Address - Street 2:SUITE A
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4298
Mailing Address - Country:US
Mailing Address - Phone:253-537-0293
Mailing Address - Fax:253-537-7650
Practice Address - Street 1:11019 CANYON RD E
Practice Address - Street 2:SUITE A
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-4298
Practice Address - Country:US
Practice Address - Phone:253-537-0293
Practice Address - Fax:253-537-7650
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003013363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP06806Medicare UPIN
WAAB15501Medicare ID - Type Unspecified