Provider Demographics
NPI:1912002262
Name:FISHFADER, VICKI
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:FISHFADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 32ND ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-3473
Mailing Address - Country:US
Mailing Address - Phone:360-293-4343
Mailing Address - Fax:
Practice Address - Street 1:912 32ND ST
Practice Address - Street 2:SUITE A
Practice Address - City:ANACORTES
Practice Address - State:WA
Practice Address - Zip Code:98221-3473
Practice Address - Country:US
Practice Address - Phone:360-293-4343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003946207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA191614OtherWORKMANS COMP
WA6927FIOtherREGENCE BLUE SHIELD 2
WA3852FIOtherREGENCE BLUE SHIELD
WA8345647Medicaid
WA3852FIOtherREGENCE BLUE SHIELD
WA6927FIOtherREGENCE BLUE SHIELD 2