Healthcare Provider Details

I. General information

NPI: 1164276804
Provider Name (Legal Business Name): FISHER PROFESSIONAL HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2024
Last Update Date: 04/17/2024
Certification Date: 02/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 N TENAYA WAY STE 120
LAS VEGAS NV
89128-0479
US

IV. Provider business mailing address

10609 UMBRELLA TREE CT
LAS VEGAS NV
89144-1440
US

V. Phone/Fax

Practice location:
  • Phone: 702-769-7087
  • Fax: 702-441-7101
Mailing address:
  • Phone: 702-769-7087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH FISHER
Title or Position: BOARD
Credential:
Phone: 702-769-7087