Healthcare Provider Details

I. General information

NPI: 1093586281
Provider Name (Legal Business Name): MICHAEL SHAUN FISHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 REDWOOD DR
SAINT CLAIR MO
63077-2018
US

IV. Provider business mailing address

1335 REDWOOD DR
SAINT CLAIR MO
63077-2018
US

V. Phone/Fax

Practice location:
  • Phone: 636-358-3019
  • Fax:
Mailing address:
  • Phone: 636-358-3019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number320900000X
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: