Provider Demographics
NPI:1164170767
Name:BITTNER, KALISSA MADISON (PA)
Entity Type:Individual
Prefix:
First Name:KALISSA
Middle Name:MADISON
Last Name:BITTNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17001 OWENSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47720-7203
Mailing Address - Country:US
Mailing Address - Phone:812-453-0738
Mailing Address - Fax:
Practice Address - Street 1:762 14TH ST
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-3413
Practice Address - Country:US
Practice Address - Phone:775-738-5850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8258-5446-1481OtherNATIONAL REGISTRY OF EMERGENCY MEDICAL TECHNICIANS