Provider Demographics
NPI:1720062417
Name:FISHER, LANCE STEVEN (PA)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:STEVEN
Last Name:FISHER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13512 W READE AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD PARK
Mailing Address - State:AZ
Mailing Address - Zip Code:85340-4019
Mailing Address - Country:US
Mailing Address - Phone:623-535-4372
Mailing Address - Fax:
Practice Address - Street 1:5702 W CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031
Practice Address - Country:US
Practice Address - Phone:623-848-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2412207P00000X
MN11450207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ538192Medicaid
AZ860373636OtherHUMANA GROUP
AZAW1436OtherHEALTHNET GROUP
AZ3981220OtherEVERCARE GROUP
AZ453051001OtherGROUP HEALTH GROUP
P14358Medicare UPIN
AZ538192Medicaid