Provider Demographics
NPI:1447426945
Name:FISHER, ETHAN SCOTT (LAC)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:SCOTT
Last Name:FISHER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1448 E CENTER ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4132
Mailing Address - Country:US
Mailing Address - Phone:208-232-2986
Mailing Address - Fax:
Practice Address - Street 1:1448 E CENTER ST
Practice Address - Street 2:SUITE D
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4132
Practice Address - Country:US
Practice Address - Phone:208-232-2986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-180171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist