Provider Demographics
NPI:1376500124
Name:KOLESAR, LISA MARGARET (DPT, ACT/L)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARGARET
Last Name:KOLESAR
Suffix:
Gender:F
Credentials:DPT, ACT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 S PHILLIPPI ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-3646
Mailing Address - Country:US
Mailing Address - Phone:208-866-7428
Mailing Address - Fax:
Practice Address - Street 1:7979 W RIFLEMAN ST STE 100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9066
Practice Address - Country:US
Practice Address - Phone:208-377-3850
Practice Address - Fax:208-658-1360
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1988225100000X
ID2342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDTD492OtherBLUE CROSS OF IDAHO
ID000010142952OtherBLUE SHIELD OF IDAHO
ID805753950Medicaid
IDTD492OtherBLUE CROSS OF IDAHO