MEDICARE: THERESA LANE FISHER P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA011	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780898577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA LANE FISHER P.A.

Provider Business Mailing Address
First Line	:	4436 NORTH STATE STREET, SUITE AI
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-3073
Country	:	US
Telephone Number	:	769-257-5336
Fax Number	:	769-257-5339

Provider Business Practice Location Address
First Line	:	4436 NORTH STATE STREET, SUITE AI
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-3073
Country	:	US
Telephone Number	:	769-257-5336
Fax Number	:	769-257-5339

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/10/2007
Last Update Date	:	04/13/2012

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Directions to “ THERESA LANE FISHER P.A.” Practice Location

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