Provider Demographics
NPI:1700221751
Name:HILL, KISH L (PA-C)
Entity Type:Individual
Prefix:
First Name:KISH
Middle Name:L
Last Name:HILL
Suffix:
Gender:F
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 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9646
Mailing Address - Fax:239-343-9681
Practice Address - Street 1:8960 COLONIAL CENTER DR STE 202
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7810
Practice Address - Country:US
Practice Address - Phone:239-343-9646
Practice Address - Fax:239-343-9681
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12-0839247200000X
CA55141363A00000X
FLPA9117324363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119551400Medicaid