Provider Demographics
NPI:1053387225
Name:FISH, JON (CRNA)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:
Last Name:FISH
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:8990 SPRINGBROOK DR NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-5884
Mailing Address - Country:US
Mailing Address - Phone:763-398-0099
Mailing Address - Fax:763-398-0124
Practice Address - Street 1:4050 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2522
Practice Address - Country:US
Practice Address - Phone:763-236-6000
Practice Address - Fax:763-236-6789
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR105914-4367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN451M8FIOtherBCBSMN
MN441652000Medicaid
MN430005342Medicare PIN