Provider Demographics
NPI:1922122811
Name:FISHER, RANDALL S (DPM)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:S
Last Name:FISHER
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 1:11014 19TH AVE SE
Mailing Address - Street 2:STE. 8 PMB #320
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5132
Mailing Address - Country:US
Mailing Address - Phone:425-252-0203
Mailing Address - Fax:425-337-5961
Practice Address - Street 1:8610 EASTVIEW AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3516
Practice Address - Country:US
Practice Address - Phone:425-252-0203
Practice Address - Fax:425-337-5961
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000474213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1078963Medicaid
WA1078963Medicaid