Provider Demographics
NPI:1790121788
Name:FISKE-BAIER, JASON (DPM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FISKE-BAIER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PENNSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18073-1312
Mailing Address - Country:US
Mailing Address - Phone:215-679-5393
Mailing Address - Fax:215-679-9674
Practice Address - Street 1:158 MAIN ST
Practice Address - Street 2:
Practice Address - City:PENNSBURG
Practice Address - State:PA
Practice Address - Zip Code:18073-1312
Practice Address - Country:US
Practice Address - Phone:215-679-5393
Practice Address - Fax:215-679-9674
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006468213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1031278010004Medicaid