Provider Demographics
NPI:1346498086
Name:KISSICK, SHAWN FREDERICK (LAC)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:FREDERICK
Last Name:KISSICK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER
Mailing Address - State:PA
Mailing Address - Zip Code:15009-2283
Mailing Address - Country:US
Mailing Address - Phone:724-774-8729
Mailing Address - Fax:
Practice Address - Street 1:455 3RD ST APT 2
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:PA
Practice Address - Zip Code:15009-2266
Practice Address - Country:US
Practice Address - Phone:724-774-8729
Practice Address - Fax:878-201-3089
Is Sole Proprietor?:No
Enumeration Date:2008-09-06
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK000926171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist