Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 0104557479 | VA |
NPI | 1649770173 |
---|---|
Provider Name | Forrest Joseph Fisher |
First Address | Reston, VA 20190-5289 |
Second Address | Reston, VA 20190-5289 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/02/2018 |
Last Update Date | 21/02/2018 |