Provider Demographics
NPI:1174397004
Name:FISHER, RUSSELL EDWARD JR
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:EDWARD
Last Name:FISHER
Suffix:JR
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 1:29033 229TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:BLACK DIAMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98010-1249
Mailing Address - Country:US
Mailing Address - Phone:971-439-5944
Mailing Address - Fax:
Practice Address - Street 1:733 7TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-5657
Practice Address - Country:US
Practice Address - Phone:206-717-8161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA161335894225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant