Provider Demographics
NPI:1053432815
Name:FISCHER, GERALD C (MPAS, ATC)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:C
Last Name:FISCHER
Suffix:
Gender:M
Credentials:MPAS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1348 E SILVERCREST DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84093-2321
Mailing Address - Country:US
Mailing Address - Phone:801-568-1789
Mailing Address - Fax:
Practice Address - Street 1:127 S 500 E STE 140
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2076
Practice Address - Country:US
Practice Address - Phone:801-587-6307
Practice Address - Fax:801-587-6313
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4977407-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant