Provider Demographics
NPI:1154326676
Name:KIESEL, DENNIS (PA-C)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:KIESEL
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 1:1000 E 1ST ST
Mailing Address - Street 2:STE 404
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:775-786-3040
Mailing Address - Fax:775-786-1386
Practice Address - Street 1:555 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4723
Practice Address - Country:US
Practice Address - Phone:775-786-3040
Practice Address - Fax:775-786-1386
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9794363AS0400X
NVPA1490363A00000X, 363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV107649Medicare PIN
MNP84621Medicare UPIN