Provider Demographics
NPI:1932744224
Name:FISH, MYLES
Entity Type:Individual
Prefix:MR
First Name:MYLES
Middle Name:
Last Name:FISH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 N KNOLL TER
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53222-3366
Mailing Address - Country:US
Mailing Address - Phone:414-659-2973
Mailing Address - Fax:
Practice Address - Street 1:770 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-2203
Practice Address - Country:US
Practice Address - Phone:414-288-3067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer