Individual
SIS E OSTOLASA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
3025 W CHERRY LANE, STE B, MERIDIAN, ID 83642
(208) 302-6450
(208) 302-6455
Mailing address
3340 E GOLDSTONE WAY, MERIDIAN, ID 83642
(208) 302-6450
(208) 302-6455
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
PA386
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
806249800
—
ID
Enumeration date
06/17/2006
Last updated
11/15/2016
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