Provider Demographics
NPI:1063517506
Name:FISHER, HENRY KENNETH (MD)
Entity type:Individual
Prefix:MR
First Name:HENRY
Middle Name:KENNETH
Last Name:FISHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2704
Mailing Address - Country:US
Mailing Address - Phone:307-266-3174
Mailing Address - Fax:307-261-6713
Practice Address - Street 1:1230 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2704
Practice Address - Country:US
Practice Address - Phone:307-266-3174
Practice Address - Fax:307-261-6713
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28508207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C0285080Medicaid
CA00C0285080Medicaid
C28508Medicare ID - Type Unspecified