Provider Demographics
NPI:1699892471
Name:FISH, IAN MATTHEW (PTA)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:MATTHEW
Last Name:FISH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 CONCORD PLACE RD
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-7826
Mailing Address - Country:US
Mailing Address - Phone:803-781-5785
Mailing Address - Fax:
Practice Address - Street 1:508 CONCORD PLACE RD
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-7826
Practice Address - Country:US
Practice Address - Phone:803-781-5785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant