Provider Demographics
NPI:1770194003
Name:KIERSKI, KATHLEEN MAHER (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MAHER
Last Name:KIERSKI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:ANN
Other - Last Name:MAHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:6800 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-7133
Practice Address - Country:US
Practice Address - Phone:919-235-1939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-11
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10863363A00000X, 363AM0700X, 363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1770194003Medicaid