Provider Demographics
NPI:1760021158
Name:FISHER, KYLE (ATC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:ANNVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17003-1404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ANNVILLE
Practice Address - State:PA
Practice Address - Zip Code:17003-1404
Practice Address - Country:US
Practice Address - Phone:717-867-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-02
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARTO0004692083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine