Healthcare Provider Details

I. General information

NPI: 1588421663
Provider Name (Legal Business Name): FISHER WADLOW FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 MAPLE VALLEY DR
FARMINGTON MO
63640-1981
US

IV. Provider business mailing address

555 W PINE ST
FARMINGTON MO
63640-1439
US

V. Phone/Fax

Practice location:
  • Phone: 573-760-8253
  • Fax:
Mailing address:
  • Phone: 573-747-1510
  • Fax: 573-474-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2024010299
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2024010299
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: