Healthcare Provider Details

I. General information

NPI: 1780902619
Provider Name (Legal Business Name): MICHAEL WESLEY FISH LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 05/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8408 133RD ST E
PUYALLUP WA
98373-2596
US

IV. Provider business mailing address

8408 133RD ST E
PUYALLUP WA
98373-2596
US

V. Phone/Fax

Practice location:
  • Phone: 253-335-9438
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number226437
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: