Provider Demographics
NPI:1003286709
Name:KISER, SHANE TRAVIS (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:TRAVIS
Last Name:KISER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 FLEMINGSBURG RD
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1015
Mailing Address - Country:US
Mailing Address - Phone:606-780-5500
Mailing Address - Fax:606-783-7281
Practice Address - Street 1:245 FLEMINGSBURG RD
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1015
Practice Address - Country:US
Practice Address - Phone:606-780-5500
Practice Address - Fax:606-783-7281
Is Sole Proprietor?:No
Enumeration Date:2015-10-07
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100394790Medicaid
KYPA2034OtherKY MEDICAL LICENSE