Provider Demographics
NPI:1306839741
Name:FISHER, MYRNA CLARE (APPN)
Entity Type:Individual
Prefix:MRS
First Name:MYRNA
Middle Name:CLARE
Last Name:FISHER
Suffix:
Gender:F
Credentials:APPN
Other - Prefix:
Other - First Name:MYRNA
Other - Middle Name:
Other - Last Name:OLSON-FISHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:777 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9251
Practice Address - Country:US
Practice Address - Phone:208-514-2500
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP193A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1306839741Medicaid
ID0043801Medicaid
ID20004216Medicare PIN
ID0043801Medicaid
ID20004219Medicare PIN
ID1306839741Medicaid
IDS16619Medicare UPIN
ID20004218Medicare PIN
ID20004215Medicare PIN