Provider Demographics
NPI:1669467833
Name:CARLISLE, KEVIN K (PA)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:K
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:PA
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 21686
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33622-1686
Mailing Address - Country:US
Mailing Address - Phone:813-343-5500
Mailing Address - Fax:866-462-7445
Practice Address - Street 1:12880 COMMODITY PL
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3101
Practice Address - Country:US
Practice Address - Phone:813-343-5500
Practice Address - Fax:866-462-7445
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA1682363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL650420578OtherCHAMPUS/TRICARE
FLX1592OtherBLUE CROSS BLUE SHIELD
FL290188900Medicaid
FLS52191Medicare UPIN
FL290188900Medicaid