Healthcare Provider Details

I. General information

NPI: 1053383075
Provider Name (Legal Business Name): SHIRLEY A FISKE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 08/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19829 N 27TH AVE
PHOENIX AZ
85027-4001
US

IV. Provider business mailing address

10835 N 25TH AVE STE 240
PHOENIX AZ
85029-3458
US

V. Phone/Fax

Practice location:
  • Phone: 623-879-5720
  • Fax:
Mailing address:
  • Phone: 602-943-9200
  • Fax: 602-216-3000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number1658
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: