Provider Demographics
NPI:1558743021
Name:FISHER, GRANT WILLIAM
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:WILLIAM
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 AIRPORT BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32504-5930
Mailing Address - Country:US
Mailing Address - Phone:850-477-6966
Mailing Address - Fax:
Practice Address - Street 1:2065 AIRPORT BLVD STE 300
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-5930
Practice Address - Country:US
Practice Address - Phone:850-477-6966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT 14996261QX0100X
LAOTT.200727261QX0100X
FLOT 17076261QX0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine