Provider Demographics
NPI:1578903100
Name:FISHER, TUESDAY FAWN (MD)
Entity Type:Individual
Prefix:
First Name:TUESDAY
Middle Name:FAWN
Last Name:FISHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 S 1ST ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7661
Practice Address - Country:US
Practice Address - Phone:217-383-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
VA0101257111207X00000X
IL036166570207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No171000000XOther Service ProvidersMilitary Health Care Provider