Healthcare Provider Details

I. General information

NPI: 1366493959
Provider Name (Legal Business Name): STEPHEN M FISH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 MAIN AVE S
NORTH BEND WA
98045-8215
US

IV. Provider business mailing address

PO BOX 969
SNOQUALMIE WA
98065-0969
US

V. Phone/Fax

Practice location:
  • Phone: 425-888-5511
  • Fax: 425-888-5513
Mailing address:
  • Phone: 425-888-5511
  • Fax: 425-888-5513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00024257
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: