Healthcare Provider Details

I. General information

NPI: 1659415099
Provider Name (Legal Business Name): KENNETH G FISHER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 E PARKDALE AVE
MANISTEE MI
49660-9709
US

IV. Provider business mailing address

1465 E PARKDALE AVE
MANISTEE MI
49660-9709
US

V. Phone/Fax

Practice location:
  • Phone: 231-398-1000
  • Fax:
Mailing address:
  • Phone: 231-398-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704208606
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: