Provider Demographics
NPI:1801490081
Name:FISHMAN, JESSE S
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:S
Last Name:FISHMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 E 1ST AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-2444
Mailing Address - Country:US
Mailing Address - Phone:303-428-6089
Mailing Address - Fax:
Practice Address - Street 1:340 E 1ST AVE STE 100
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-2444
Practice Address - Country:US
Practice Address - Phone:303-428-6089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-28
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
NY028608363A00000X
CO0008198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program