Provider Demographics
NPI:1407137334
Name:FISCHER, KYLE A (PA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:FISCHER
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22262 NE GLISAN ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8553
Mailing Address - Country:US
Mailing Address - Phone:698-712-1333
Mailing Address - Fax:
Practice Address - Street 1:1821 S STOUGHTON RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-2257
Practice Address - Country:US
Practice Address - Phone:608-260-6000
Practice Address - Fax:608-260-6161
Is Sole Proprietor?:No
Enumeration Date:2011-09-06
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2782023363A00000X
CAPA66213363A00000X
ORPA194316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400216879Medicare PIN