Provider Demographics
NPI:1124309224
Name:THACKER, ROBERT SLADE (APRN CFNP)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:SLADE
Last Name:THACKER
Suffix:
Gender:M
Credentials:APRN CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 FAIRVIEW AVE
Mailing Address - Street 2:STE. 230
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-5407
Mailing Address - Country:US
Mailing Address - Phone:208-459-4667
Mailing Address - Fax:
Practice Address - Street 1:1906 FAIRVIEW AVE
Practice Address - Street 2:STE. 230
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-5407
Practice Address - Country:US
Practice Address - Phone:208-459-4667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1096A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily