Provider Demographics
NPI:1316048564
Name:FISHER, WILLIS (CRNA)
Entity type:Individual
Prefix:
First Name:WILLIS
Middle Name:
Last Name:FISHER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:617 S RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-1643
Mailing Address - Country:US
Mailing Address - Phone:715-732-8855
Mailing Address - Fax:
Practice Address - Street 1:617 S RAYMOND ST
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-1643
Practice Address - Country:US
Practice Address - Phone:715-732-8855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI022491367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI103339631Medicaid
430036342OtherMEDICARE RAILROAD
WI43335500Medicaid