Healthcare Provider Details

I. General information

NPI: 1497744338
Provider Name (Legal Business Name): CHADWICK ALDEN FISHER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6051 W EMERALD STREET
BOISE ID
83704
US

IV. Provider business mailing address

3340 E GOLDSTONE WAY
MERIDIAN ID
83642
US

V. Phone/Fax

Practice location:
  • Phone: 208-302-5150
  • Fax: 208-302-5155
Mailing address:
  • Phone: 208-302-5150
  • Fax: 208-302-5155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number01567
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3909
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1592
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: