Provider Demographics
NPI:1447221932
Name:FOX, JON R (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:R
Last Name:FOX
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10798 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1329
Mailing Address - Country:US
Mailing Address - Phone:208-377-3368
Mailing Address - Fax:208-322-4691
Practice Address - Street 1:10798 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-377-3368
Practice Address - Fax:208-322-4691
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-001388363A00000X
IDPA-1083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970025826OtherRAILRAOD MEDICARE
P10204Medicare UPIN
588540Medicare UPIN