Provider Demographics
NPI:1578910915
Name:FISH, KIMBERLY (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
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:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44871-0378
Mailing Address - Country:US
Mailing Address - Phone:419-609-1112
Mailing Address - Fax:419-502-3537
Practice Address - Street 1:5319 HOAG DR STE 111
Practice Address - Street 2:
Practice Address - City:SHEFFIELD VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44035-1492
Practice Address - Country:US
Practice Address - Phone:440-934-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.004651RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant