Provider Demographics
NPI:1073618880
Name:KISTLER, EUGENE PATRICK (PA-C)
Entity Type:Individual
Prefix:MR
First Name:EUGENE
Middle Name:PATRICK
Last Name:KISTLER
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 1:4500 STUART ST
Mailing Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29207-5700
Mailing Address - Country:US
Mailing Address - Phone:803-751-2618
Mailing Address - Fax:
Practice Address - Street 1:4500 STUART ST
Practice Address - Street 2:MONCRIEF ARMY COMMUNITY HOSPITAL
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-5700
Practice Address - Country:US
Practice Address - Phone:803-751-2618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCPA 1020290363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical