MEDICARE: SIS E OSTOLASA PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	PA386	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013952761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIS E OSTOLASA PA

Provider Business Mailing Address
First Line	:	3340 E GOLDSTONE WAY
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642
Country	:	US
Telephone Number	:	208-302-6450
Fax Number	:	208-302-6455

Provider Business Practice Location Address
First Line	:	3025 W CHERRY LANE
Second Line	:	STE B
City	:	MERIDIAN
State	:	ID
Zip	:	83642
Country	:	US
Telephone Number	:	208-302-6450
Fax Number	:	208-302-6455

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2006
Last Update Date	:	11/15/2016

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Directions to “ SIS E OSTOLASA PA” Practice Location

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