Healthcare Provider Details

I. General information

NPI: 1144271412
Provider Name (Legal Business Name): LILLIAN E MARESCA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 09/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73265 CONFEDERATED WAY
PENDLETON OR
97801-0160
US

IV. Provider business mailing address

2306 PALOUSE ST
BOISE ID
83705-3565
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-9830
  • Fax: 541-278-7575
Mailing address:
  • Phone: 208-378-4288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberM6636
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: