Provider Demographics
NPI:1730946229
Name:FISH, DEREK ZACHARY (DO STUDENT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:ZACHARY
Last Name:FISH
Suffix:
Gender:M
Credentials:DO STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9716 203RD ST E
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98338-8573
Mailing Address - Country:US
Mailing Address - Phone:253-370-7312
Mailing Address - Fax:
Practice Address - Street 1:9716 203RD ST E
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:WA
Practice Address - Zip Code:98338-8573
Practice Address - Country:US
Practice Address - Phone:253-370-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-01
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program