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General NPI Number Information
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NPI Number | 1174693543
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Entity Type | Individual
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Provider Name | CHRIS CHADWICK FUGATE CRNA
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Gender | Male
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Dates
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Enumeration Date | 11/09/2006
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Last Update Date | 11/10/2020
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Provider Practice Location Address
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Address Line | 256 N 2ND E
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City | REXBURG
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State | ID
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Zip | 83440-1638
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Country | US
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Telephone | 208-656-9646
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3659
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City | IDAHO FALLS
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State | ID
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Zip | 83403-3659
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Country | US
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Telephone | 208-525-2090
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Fax | 208-525-2662
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | N-16877
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License Number State | ID
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