Provider Demographics
NPI:1477107837
Name:VISCA, KAYLA M
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:M
Last Name:VISCA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KAYLA
Other - Middle Name:M
Other - Last Name:GREGG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2 S CASCADE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1604
Mailing Address - Country:US
Mailing Address - Phone:719-538-2900
Mailing Address - Fax:719-538-2990
Practice Address - Street 1:15909 JACKSON CREEK PKWY
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-8693
Practice Address - Country:US
Practice Address - Phone:719-522-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60956859363A00000X
COPA.0007765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000213809Medicaid
COPA.0007765OtherCOLORADO LICENSE