Provider Demographics
NPI:1043296684
Name:FISHER, AUDREY ANN (PAC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ANN
Last Name:FISHER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:ANN
Other - Last Name:BUTLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 E LEHIGH AVE
Mailing Address - Street 2:CHC-2
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-1012
Mailing Address - Country:US
Mailing Address - Phone:215-707-1840
Mailing Address - Fax:215-707-8570
Practice Address - Street 1:100 E LEHIGH AVE
Practice Address - Street 2:CHC-2
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19125-1012
Practice Address - Country:US
Practice Address - Phone:215-707-1840
Practice Address - Fax:215-707-8570
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA00125L363A00000X
PAOA000233L363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACD4829OtherRAILROADMEDICARE
PA597586OtherMEDICARE GROUP
PA597586OtherMEDICARE GROUP