Provider Demographics
NPI:1275603086
Name:SWAN, LISA M (PT949)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:SWAN
Suffix:
Gender:F
Credentials:PT949
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 W SHORELINE DR
Mailing Address - Street 2:SUITE 230
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6750
Mailing Address - Country:US
Mailing Address - Phone:208-343-4700
Mailing Address - Fax:208-343-4706
Practice Address - Street 1:1673 W SHORELINE DR
Practice Address - Street 2:SUITE 230
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6750
Practice Address - Country:US
Practice Address - Phone:208-343-4700
Practice Address - Fax:208-343-4706
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT949225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist