Provider Demographics
NPI:1760781926
Name:FISHBURN, MICHAEL THOMAS (RPA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:FISHBURN
Suffix:
Gender:M
Credentials:RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28837 W KALONG CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-5665
Mailing Address - Country:US
Mailing Address - Phone:248-358-2979
Mailing Address - Fax:248-358-5012
Practice Address - Street 1:28837 W KALONG CIR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-5665
Practice Address - Country:US
Practice Address - Phone:248-358-2979
Practice Address - Fax:248-358-5012
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant