Provider Demographics
NPI:1568680874
Name:FISHBACK, DAWN (PA-C)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:
Last Name:FISHBACK
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 1:1520 SAN PABLO ST
Mailing Address - Street 2:STE 3800
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-5310
Mailing Address - Country:US
Mailing Address - Phone:323-442-5720
Mailing Address - Fax:323-442-7543
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:STE 3800
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5720
Practice Address - Fax:323-442-7543
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 12877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABT801ZOtherPTAN
CAM050696Medicare UPIN
CAWPA12877AMedicare ID - Type UnspecifiedMEDICARE ID