Basic Information
| Provider Information | |||||||||
| NPI: | 1144271412 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARESCA | ||||||||
| FirstName: | LILLIAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2306 PALOUSE ST | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837053565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083784288 | ||||||||
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| Practice Location | |||||||||
| Address1: | 73265 CONFEDERATED WAY | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978010160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419669830 | ||||||||
| FaxNumber: | 5412787575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M6636 | ID | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1346283488 | 01 | OR | TRIBAL CLINIC NPPES | OTHER | 171037 | 05 | OR | MEDICAID | 8TA265 | 01 | OR | MEDICARE/TRAILBLAZER | OTHER |