Provider Demographics
NPI:1639668304
Name:FISHER, SHANE (PT, DPT)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 SW 34TH ST APT Q88
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-6549
Mailing Address - Country:US
Mailing Address - Phone:561-876-5800
Mailing Address - Fax:
Practice Address - Street 1:4343 W NEWBERRY RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-2817
Practice Address - Country:US
Practice Address - Phone:352-373-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305211865225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist