Healthcare Provider Details

I. General information

NPI: 1245068535
Provider Name (Legal Business Name): ANASTASIA FISH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 07/26/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 W 761ST TANK BATTALION AVE
FORT HOOD TX
76544
US

IV. Provider business mailing address

3009 IRA YOUNG DR APT 501
TEMPLE TX
76504-6311
US

V. Phone/Fax

Practice location:
  • Phone: 254-287-5410
  • Fax:
Mailing address:
  • Phone: 310-944-2915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1221526
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: