Provider Demographics
NPI:1811961881
Name:FISCHER, STEVEN EUGENE (PAC)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:EUGENE
Last Name:FISCHER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2983
Mailing Address - Country:US
Mailing Address - Phone:208-882-2011
Mailing Address - Fax:208-883-1853
Practice Address - Street 1:623 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2983
Practice Address - Country:US
Practice Address - Phone:208-882-2011
Practice Address - Fax:208-883-1853
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA74363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002399700Medicaid
S63127Medicare UPIN
1665574Medicare ID - Type Unspecified