Provider Demographics
NPI:1013952761
Name:OSTOLASA, SIS E (PA)
Entity Type:Individual
Prefix:
First Name:SIS
Middle Name:E
Last Name:OSTOLASA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-6450
Mailing Address - Fax:208-302-6455
Practice Address - Street 1:3025 W CHERRY LANE
Practice Address - Street 2:STE B
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642
Practice Address - Country:US
Practice Address - Phone:208-302-6450
Practice Address - Fax:208-302-6455
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA386363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806249800Medicaid
P83595Medicare UPIN
ID1667539Medicare PIN
ID1667530Medicare PIN