Provider Demographics
NPI:1639212962
Name:FISHER, DIANN M (PA)
Entity Type:Individual
Prefix:
First Name:DIANN
Middle Name:M
Last Name:FISHER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 PENN AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55431-2319
Mailing Address - Country:US
Mailing Address - Phone:612-226-6929
Mailing Address - Fax:
Practice Address - Street 1:2330 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-3710
Practice Address - Country:US
Practice Address - Phone:612-781-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA822363A00000X
MN10499363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVS89331Medicare UPIN