MEDICARE: REXFORD REYNOLD FISHER III PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	0010-11302	NC
2	363A00000X	Physician Assistant	0010-11302	NC
3	363AS0400X	Surgical Physician Assistant	0010-11302	NC
4	390200000X	Student in an Organized Health Care Education/Training Program
5	363AM0700X	Medical Physician Assistant		NC

General Provider Information

NPI Number	:	1629685912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REXFORD REYNOLD FISHER III PA-C

Provider Business Mailing Address
First Line	:	6615 ACADEMIC AVE
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-8094
Country	:	US
Telephone Number	:	585-694-0715
Fax Number	:

Provider Business Practice Location Address
First Line	:	6615 ACADEMIC AVE
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-8094
Country	:	US
Telephone Number	:	585-694-0715
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2020
Last Update Date	:	12/01/2023

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