Healthcare Provider Details

I. General information

NPI: 1700878949
Provider Name (Legal Business Name): MAHANA S FISHER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 N 400 W
BLANDING UT
84511-3417
US

IV. Provider business mailing address

PO BOX 130
MONTEZUMA CREEK UT
84534
US

V. Phone/Fax

Practice location:
  • Phone: 435-678-2254
  • Fax: 435-678-2534
Mailing address:
  • Phone: 435-651-3700
  • Fax: 435-651-3376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4759456-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: