Provider Demographics
NPI:1467410803
Name:KISHBAUGH, MARK DONALD (PA-C)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:DONALD
Last Name:KISHBAUGH
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:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:MT
Mailing Address - Zip Code:59632-0044
Mailing Address - Country:US
Mailing Address - Phone:406-224-2244
Mailing Address - Fax:
Practice Address - Street 1:214 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:MT
Practice Address - Zip Code:59632-7640
Practice Address - Country:US
Practice Address - Phone:406-225-4201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1960363AM0700X
CO2500363AM0700X
MT43812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68421532Medicaid
CO300691Medicare PIN
CO68421532Medicaid
AZS93234Medicare UPIN