Provider Demographics
NPI:1871152686
Name:FISHER, NOLAN (DO)
Entity type:Individual
Prefix:
First Name:NOLAN
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 E CAMELBACK RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2718
Mailing Address - Country:US
Mailing Address - Phone:602-521-3550
Mailing Address - Fax:602-635-6572
Practice Address - Street 1:4200 E CAMELBACK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2718
Practice Address - Country:US
Practice Address - Phone:602-521-3550
Practice Address - Fax:602-635-6572
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-09974207R00000X
AZ010199208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ127324Medicaid