Healthcare Provider Details

I. General information

NPI: 1689022519
Provider Name (Legal Business Name): THOMAS DANIEL FIFE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 CLINIC RD
CHALLIS ID
83226
US

IV. Provider business mailing address

611 CLINIC RD
CHALLIS ID
83226
US

V. Phone/Fax

Practice location:
  • Phone: 208-879-4351
  • Fax: 208-879-5216
Mailing address:
  • Phone: 208-879-4351
  • Fax: 208-879-5216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-1371
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: