Provider Demographics
NPI:1790340974
Name:PAUL KISUCKY LLC
Entity Type:Organization
Organization Name:PAUL KISUCKY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KISUCKY
Authorized Official - Suffix:III
Authorized Official - Credentials:CRNA
Authorized Official - Phone:915-301-5091
Mailing Address - Street 1:205 W BOUTZ RD BLDG 1
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-3259
Mailing Address - Country:US
Mailing Address - Phone:575-532-7033
Mailing Address - Fax:575-556-7139
Practice Address - Street 1:925 S WALNUT ST
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3955
Practice Address - Country:US
Practice Address - Phone:575-523-6330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-03
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty