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General NPI Number Information
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NPI Number | 1295138568
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Entity Type | Individual
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Provider Name | WILLIAM SHANE FISHER
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Gender | Male
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Dates
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Enumeration Date | 10/01/2014
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Last Update Date | 05/16/2019
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Provider Practice Location Address
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Address Line | 6005 E ABINEAU CANYON DR
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City | FLAGSTAFF
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State | AZ
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Zip | 86004-7168
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Country | US
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Telephone | 928-635-6750
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 30354
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City | FLAGSTAFF
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State | AZ
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Zip | 86003-0354
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Country | US
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Telephone | 928-635-6750
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | AL8133H
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License Number State | AZ
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