Provider Demographics
NPI:1972259026
Name:FISKE, TAYLOR
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:FISKE
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 1:7054 26TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7199
Mailing Address - Country:US
Mailing Address - Phone:701-429-4097
Mailing Address - Fax:
Practice Address - Street 1:1605 UNIVERSITY DR S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-4189
Practice Address - Country:US
Practice Address - Phone:701-293-3060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRPH5950183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist