Provider Demographics
NPI:1063455608
Name:ROPER, LISA MARIE (BS, ATC, LAT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:ROPER
Suffix:
Gender:F
Credentials:BS, ATC, LAT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS, ATC/LAT
Mailing Address - Street 1:4075 N TALLGRASS AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-2613
Mailing Address - Country:US
Mailing Address - Phone:208-936-5445
Mailing Address - Fax:
Practice Address - Street 1:1900 W PINE AVE
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1961
Practice Address - Country:US
Practice Address - Phone:208-350-4160
Practice Address - Fax:208-350-4178
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2016-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAT-AT-1486632255A2300X
IDAT-374225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1063455608OtherAT-374