Provider Demographics
NPI:1134199631
Name:SMITH, CHERISH L (PA)
Entity type:Individual
Prefix:
First Name:CHERISH
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHERISH
Other - Middle Name:L
Other - Last Name:ESTEP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-381-4101
Practice Address - Street 1:300 E JEFFERSON ST
Practice Address - Street 2:SUITE 300
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6246
Practice Address - Country:US
Practice Address - Phone:208-381-4100
Practice Address - Fax:208-381-4101
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010149864OtherREGENCE BLUE SHIELD
IDPAVE5OtherTRUE BLUE
ID806367900Medicaid
ID40659OtherBLUE CROSS
IDP61862Medicare UPIN
ID1667510Medicare ID - Type Unspecified