Provider Demographics
NPI:1922000124
Name:FISHER, WESLEY C (PAC)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:C
Last Name:FISHER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 OSBORN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1883
Mailing Address - Country:US
Mailing Address - Phone:906-632-1800
Mailing Address - Fax:906-632-2199
Practice Address - Street 1:601 OSBORN BLVD
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1883
Practice Address - Country:US
Practice Address - Phone:906-632-1800
Practice Address - Fax:906-632-2199
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003314363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIQ19508Medicare UPIN
MIN94330001Medicare ID - Type Unspecified