Healthcare Provider Details

I. General information

NPI: 1760847420
Provider Name (Legal Business Name): ANTONIO FISH PP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 FULTON INDUSTRIAL BLVD SW
ATLANTA GA
30336-2659
US

IV. Provider business mailing address

1449 RAINTREE DR APT J
ROSWELL GA
30076-2717
US

V. Phone/Fax

Practice location:
  • Phone: 404-346-3471
  • Fax:
Mailing address:
  • Phone: 678-748-0010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: