Provider Demographics
NPI:1174693543
Name:FUGATE, CHRIS CHADWICK (CRNA)
Entity type:Individual
Prefix:MR
First Name:CHRIS
Middle Name:CHADWICK
Last Name:FUGATE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3659
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-3659
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-525-2662
Practice Address - Street 1:256 N 2ND E
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1638
Practice Address - Country:US
Practice Address - Phone:208-656-9646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-16877367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0043670Medicaid
ID0043670Medicaid