Provider Demographics
NPI:1760470488
Name:KALISZEWSKI, KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KALISZEWSKI
Suffix:
Gender:M
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 1:110 BEECH ST STE B
Mailing Address - Street 2:
Mailing Address - City:TAWAS CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48763-8314
Mailing Address - Country:US
Mailing Address - Phone:989-362-9859
Mailing Address - Fax:989-362-9862
Practice Address - Street 1:110 BEECH ST
Practice Address - Street 2:SUITE B
Practice Address - City:TAWAS CITY
Practice Address - State:MI
Practice Address - Zip Code:48763-8314
Practice Address - Country:US
Practice Address - Phone:989-362-1015
Practice Address - Fax:989-362-9862
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003895363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3370220Medicaid
MI3370220Medicaid
NPP000Medicare UPIN