Provider Demographics
NPI:1497744338
Name:FISHER, CHADWICK ALDEN (PA)
Entity Type:Individual
Prefix:
First Name:CHADWICK
Middle Name:ALDEN
Last Name:FISHER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-5150
Mailing Address - Fax:208-302-5155
Practice Address - Street 1:6051 W EMERALD STREET
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-302-5150
Practice Address - Fax:208-302-5155
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA015672255A2300X
MAPA3909363A00000X
IDPA-1592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPA3909OtherP.A. LICENSE NUMBER