Provider Demographics
NPI:1720261787
Name:FISKE, NATHAN (RPH)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:FISKE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 TOWNSEND RD
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:12838-2301
Mailing Address - Country:US
Mailing Address - Phone:518-632-9293
Mailing Address - Fax:
Practice Address - Street 1:3768 BURGOYNE AVENUE
Practice Address - Street 2:
Practice Address - City:HUDSDON FALLS
Practice Address - State:NY
Practice Address - Zip Code:12839
Practice Address - Country:US
Practice Address - Phone:518-746-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-13
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045779183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist