Provider Demographics
NPI:1669499133
Name:FISKE, DWIGHT (PA-C, RN, AEMT)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:FISKE
Suffix:
Gender:M
Credentials:PA-C, RN, AEMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 W 1ST ST
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-9688
Mailing Address - Country:US
Mailing Address - Phone:989-820-8127
Mailing Address - Fax:
Practice Address - Street 1:200 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-9237
Practice Address - Country:US
Practice Address - Phone:989-362-3411
Practice Address - Fax:989-362-9925
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003088363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA542502590AMedicaid
GA01147225OtherAMERIGROUP
GA542502590BMedicaid
GA542502590AMedicaid
GA01147225OtherAMERIGROUP
GA542502590BMedicaid