Healthcare Provider Details

I. General information

NPI: 1750743035
Provider Name (Legal Business Name): GRANT FISH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 06/24/2026
Certification Date:
Deactivation Date: 04/26/2019
Reactivation Date: 06/24/2026

III. Provider practice location address

803 SHARON AVE E
MOSES LAKE WA
98837-2441
US

IV. Provider business mailing address

803 SHARON AVE E
MOSES LAKE WA
98837-2441
US

V. Phone/Fax

Practice location:
  • Phone: 509-431-3814
  • Fax:
Mailing address:
  • Phone: 509-431-3814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: