Provider Demographics
NPI:1144271412
Name:MARESCA, LILLIAN E (MD)
Entity type:Individual
Prefix:
First Name:LILLIAN
Middle Name:E
Last Name:MARESCA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 PALOUSE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3565
Mailing Address - Country:US
Mailing Address - Phone:208-378-4288
Mailing Address - Fax:
Practice Address - Street 1:73265 CONFEDERATED WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-0160
Practice Address - Country:US
Practice Address - Phone:541-966-9830
Practice Address - Fax:541-278-7575
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1346283488OtherTRIBAL CLINIC NPPES
OR171037Medicaid
OR8TA265OtherMEDICARE/TRAILBLAZER
ID1130964Medicare ID - Type Unspecified
F66496Medicare UPIN