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General NPI Number Information
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NPI Number | 1780898577
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Entity Type | Individual
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Provider Name | THERESA LANE FISHER P.A.
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Gender | Female
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Dates
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Enumeration Date | 05/10/2007
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Last Update Date | 04/13/2012
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Provider Practice Location Address
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Address Line | 4436 NORTH STATE STREET, SUITE AI
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City | JACKSON
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State | MS
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Zip | 39206-3073
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Country | US
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Telephone | 769-257-5336
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Fax | 769-257-5339
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Provider Business Mailing Address
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Address Line | 4436 NORTH STATE STREET, SUITE AI
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City | JACKSON
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State | MS
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Zip | 39206-3073
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Country | US
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Telephone | 769-257-5336
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Fax | 769-257-5339
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA011
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License Number State | MS
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