MEDICARE: MS. MELISSA JEAN HUMPAL FISHER MS, ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1790773133
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MELISSA JEAN HUMPAL FISHER MS, ATC

Provider Business Mailing Address
First Line	:	14 W CLARA CT
Second Line	:
City	:	BOZEMAN
State	:	MT
Zip	:	59718-7687
Country	:	US
Telephone Number	:	406-579-3695
Fax Number	:

Provider Business Practice Location Address
First Line	:	536 S COTTONWOOD RD
Second Line	:	SUITE 100
City	:	BOZEMAN
State	:	MT
Zip	:	59718-9515
Country	:	US
Telephone Number	:	406-586-8029
Fax Number	:

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

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	03/18/2014

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