Provider Demographics
NPI:1649770173
Name:FISHER, FORREST JOSEPH
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:JOSEPH
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:FORREST
Other - Middle Name:JOSEPH
Other - Last Name:ESPINOSA-FISHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1886 METRO CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5289
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1886 METRO CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5289
Practice Address - Country:US
Practice Address - Phone:703-437-8195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557479111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology