Active NPI
Theresa Lane Fisher, P.A.
- Physician Assistant
- Jackson, MS
National Provider Identifier
1780898577
On this page
OIG exclusion record
The HHS Office of Inspector General’s List of Excluded Individuals/Entities (LEIE) contains a record with this NPI:
- Section 1128a(1) exclusion effective Feb 20, 2024.
- Section 1128a(1) exclusion effective Jan 20, 2016.
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA011
- Practice address
- 4436 North State Street, Suite Ai
Jackson, MS 39206-3073 - Phone
- (769) 257-5336
- Fax
- (769) 257-5339
- NPI assigned
- May 10, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA011 | MS | Primary |
Addresses
Primary practice location
4436 North State Street, Suite Ai
Jackson, MS 39206-3073
Mailing address
4436 North State Street, Suite Ai
Jackson, MS 39206-3073
Phone (769) 257-5336
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 00125523 | Medicaid | MS |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- HHS exclusion list flag
- Flagged The directory lists this NPI on an HHS exclusion list.
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA011 | MS | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1178755200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1334275200000",
"number": "1780898577",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4436 NORTH STATE STREET, SUITE AI",
"city": "JACKSON",
"state": "MS",
"postal_code": "392063073",
"telephone_number": "769-257-5336",
"fax_number": "769-257-5339"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4436 NORTH STATE STREET, SUITE AI",
"city": "JACKSON",
"state": "MS",
"postal_code": "392063073",
"telephone_number": "769-257-5336",
"fax_number": "769-257-5339"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LANE FISHER",
"first_name": "THERESA",
"credential": "P.A.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-05-10",
"last_updated": "2012-04-13",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "MS",
"license": "PA011",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00125523",
"state": "MS"
}
],
"endpoints": [],
"other_names": []
}Other providers in Jackson, MS
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 13, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; OIG LEIE.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.