Provider Demographics
NPI:1578936712
Name:FISHER, TYLER (PA-C)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
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 1:308 JK LN
Mailing Address - Street 2:
Mailing Address - City:KENNA
Mailing Address - State:WV
Mailing Address - Zip Code:25248-7280
Mailing Address - Country:US
Mailing Address - Phone:304-532-5435
Mailing Address - Fax:
Practice Address - Street 1:5430 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-2224
Practice Address - Country:US
Practice Address - Phone:304-925-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-10
Last Update Date:2015-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1944363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant