Provider Demographics
NPI:1801003959
Name:KIRK, CARISSA NICOLETTE (DO)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:NICOLETTE
Last Name:KIRK
Suffix:
Gender:F
Credentials:DO
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 4624
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78502-4624
Mailing Address - Country:US
Mailing Address - Phone:956-362-6683
Mailing Address - Fax:956-362-6818
Practice Address - Street 1:5540 RAPHAEL DR
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-1407
Practice Address - Country:US
Practice Address - Phone:956-362-6683
Practice Address - Fax:956-362-6818
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI76270207X00000X
NY254863207X00000X
WI20745207X00000X
GA67668207X00000X
TXP7296207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1801003959Medicaid
TX333634902Medicaid
WI100165336Medicaid