Provider Demographics
NPI:1639249196
Name:PAUL KISUCKY CRNA PC
Entity Type:Organization
Organization Name:PAUL KISUCKY CRNA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:KISUCKY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:682-365-7402
Mailing Address - Street 1:PO BOX 220717
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79913-2717
Mailing Address - Country:US
Mailing Address - Phone:682-365-7402
Mailing Address - Fax:
Practice Address - Street 1:1416 GEORGE DIETER DR
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7601
Practice Address - Country:US
Practice Address - Phone:915-252-1654
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX088570902Medicaid
00C05VOtherBLUE CROSS BLUE SHIELD
2277986OtherAETNA
2277986OtherAETNA
TX088570902Medicaid
00C05VOtherBLUE CROSS BLUE SHIELD
TX00035CMedicare PIN