Provider Demographics
NPI:1740223148
Name:SCHRADER, SCOTT D (PA)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:D
Last Name:SCHRADER
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:PO BOX 1657
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83303-1657
Mailing Address - Country:US
Mailing Address - Phone:208-734-3356
Mailing Address - Fax:208-733-9463
Practice Address - Street 1:650 ADDISON AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5444
Practice Address - Country:US
Practice Address - Phone:208-732-3429
Practice Address - Fax:208-732-3220
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805592000Medicaid
ID805592000Medicaid
ID1379299Medicare PIN
ID1666143Medicare PIN