Provider Demographics
NPI:1568467223
Name:FISHER, JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:FISHER
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 1:4421 NE ST JOHNS RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-2573
Mailing Address - Country:US
Mailing Address - Phone:360-695-9922
Mailing Address - Fax:360-695-1310
Practice Address - Street 1:4421 NE ST JOHNS RD
Practice Address - Street 2:SUITE F
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-2573
Practice Address - Country:US
Practice Address - Phone:360-695-9922
Practice Address - Fax:360-695-1310
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA10276208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0185791OtherDEPT OF LABOR & INDUSTRIE
WA8303000Medicaid
WAMD10276OtherWA STATE CRIME VICTIMS
WAMD10276OtherWA STATE CRIME VICTIMS
WAA08118Medicare UPIN