Provider Demographics
NPI:1477009587
Name:KIST, BRUCE P
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:P
Last Name:KIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 HAMILTON DR
Mailing Address - Street 2:
Mailing Address - City:SPOTSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08884-1271
Mailing Address - Country:US
Mailing Address - Phone:732-261-0234
Mailing Address - Fax:
Practice Address - Street 1:44 HAMILTON DR
Practice Address - Street 2:
Practice Address - City:SPOTSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08884-1271
Practice Address - Country:US
Practice Address - Phone:732-261-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-29
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
NJK46751007701492172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver