Provider Demographics
NPI:1780898577
Name:LANE FISHER, THERESA (PA)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:LANE FISHER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4436 NORTH STATE STREET, SUITE AI
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39206-3073
Mailing Address - Country:US
Mailing Address - Phone:769-257-5336
Mailing Address - Fax:769-257-5339
Practice Address - Street 1:4436 NORTH STATE STREET, SUITE AI
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3073
Practice Address - Country:US
Practice Address - Phone:769-257-5336
Practice Address - Fax:769-257-5339
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA011363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00125523Medicaid