Provider Demographics
NPI:1619066297
Name:TISHER, PAUL W (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:W
Last Name:TISHER
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 1:194 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743
Mailing Address - Country:US
Mailing Address - Phone:207-834-3101
Mailing Address - Fax:207-834-2917
Practice Address - Street 1:104 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743
Practice Address - Country:US
Practice Address - Phone:207-834-3101
Practice Address - Fax:207-834-2917
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2012-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0135372084P0800X
MEMD135372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MM5124Medicare ID - Type Unspecified
D80806Medicare UPIN