Healthcare Provider Details

I. General information

NPI: 1053846774
Provider Name (Legal Business Name): SHAWN D FISHER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6666 BALI HAI DRIVE
BB FL
33437
US

IV. Provider business mailing address

6666 BALI HAI DR.
BOYNTON BEACH FL
33437
US

V. Phone/Fax

Practice location:
  • Phone: 888-789-6672
  • Fax: 646-862-9066
Mailing address:
  • Phone: 888-789-6672
  • Fax: 646-862-9066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0053071
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113659
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: