Provider Demographics
NPI:1336258268
Name:FISHER, GREGORY LEE (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:FISHER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 JOE FRANK HARRIS PKWY SE
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-4221
Mailing Address - Country:US
Mailing Address - Phone:770-382-0029
Mailing Address - Fax:706-387-0306
Practice Address - Street 1:420 E 2ND AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-3209
Practice Address - Country:US
Practice Address - Phone:706-509-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA002916363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS41830Medicare UPIN
GAS41830Medicare UPIN