Provider Demographics
NPI:1588421663
Name:WADLOW, FISHER (NP)
Entity type:Individual
Prefix:
First Name:FISHER
Middle Name:
Last Name:WADLOW
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 MASON RIDGE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8509
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:534 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1981
Practice Address - Country:US
Practice Address - Phone:573-760-8253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-05
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2024010299363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily