Healthcare Provider Details

I. General information

NPI: 1922208321
Provider Name (Legal Business Name): JACOB WAYNE FISK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 05/27/2021
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

241 N BUFFALO DR STE 100
LAS VEGAS NV
89145-0307
US

IV. Provider business mailing address

241 N BUFFALO DR STE 100
LAS VEGAS NV
89145-0307
US

V. Phone/Fax

Practice location:
  • Phone: 702-852-1390
  • Fax: 702-577-3334
Mailing address:
  • Phone: 702-852-1390
  • Fax: 702-577-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberB01260
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License NumberB01260
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: