Provider Demographics
NPI:1194894113
Name:ISHIDA, VICTOR M (PA)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:M
Last Name:ISHIDA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 NW 16TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2265
Mailing Address - Country:US
Mailing Address - Phone:208-452-8050
Mailing Address - Fax:208-452-8055
Practice Address - Street 1:910 NW 16TH ST STE 101
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2265
Practice Address - Country:US
Practice Address - Phone:208-452-8050
Practice Address - Fax:208-452-8055
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA423363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR805922100Medicaid
OR108620Medicare ID - Type Unspecified
OR805922100Medicaid
ORP44161Medicare UPIN