Provider Demographics
NPI:1114584380
Name:KISH, PHILIP (DAC)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:KISH
Suffix:
Gender:M
Credentials:DAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:832 3RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:MN
Mailing Address - Zip Code:55920-9783
Mailing Address - Country:US
Mailing Address - Phone:507-261-5439
Mailing Address - Fax:
Practice Address - Street 1:3270 19TH ST NW STE 203
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-2951
Practice Address - Country:US
Practice Address - Phone:507-261-5439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1797171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist