Provider Demographics
NPI:1790277473
Name:FISHER, LYLE WAYNE
Entity Type:Individual
Prefix:
First Name:LYLE
Middle Name:WAYNE
Last Name:FISHER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11947 SOUTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-7619
Mailing Address - Country:US
Mailing Address - Phone:561-204-2213
Mailing Address - Fax:561-204-2218
Practice Address - Street 1:11947 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411
Practice Address - Country:US
Practice Address - Phone:561-204-2213
Practice Address - Fax:561-204-2218
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089421225100000X
TX1295006225100000X
FLPT33427225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist