Basic Information
| Provider Information | |||||||||
| NPI: | 1497744338 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FISHER | ||||||||
| FirstName: | CHADWICK | ||||||||
| MiddleName: | ALDEN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3340 E GOLDSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083025150 | ||||||||
| FaxNumber: | 2083025155 | ||||||||
| Practice Location | |||||||||
| Address1: | 6051 W EMERALD STREET | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83704 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083025150 | ||||||||
| FaxNumber: | 2083025155 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2005 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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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 | 2255A2300X | 01567 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | PA3909 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-1592 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.