Basic Information
| Provider Information | |||||||||
| NPI: | 1396828158 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISHER | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Practice Location | |||||||||
| Address1: | 2315 8TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835017301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087461383 | ||||||||
| FaxNumber: | 2087466348 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 03/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M3676 | ID | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD00040584 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1396828158 | 01 | ID | REGENCE BLUESHIELD | OTHER | 1089838 | 05 | WA | MEDICAID | 0171659 | 01 | WA | WA LABOR & INDUSTRIES | OTHER | DF508 | 01 | ID | BLUE CROSS | OTHER | 1396828158 | 05 | ID | MEDICAID |