Provider Demographics
NPI:1710554274
Name:FISHBAUGH, JACOB WILLIAM (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WILLIAM
Last Name:FISHBAUGH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1105 SIXTH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-2386
Mailing Address - Country:US
Mailing Address - Phone:231-392-0773
Mailing Address - Fax:231-935-5885
Practice Address - Street 1:3537 W FRONT ST STE A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7942
Practice Address - Country:US
Practice Address - Phone:231-935-0338
Practice Address - Fax:231-935-0569
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA10434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant