Provider Demographics
NPI:1831124338
Name:KISSINGER, ISOLDE (PA-C)
Entity Type:Individual
Prefix:
First Name:ISOLDE
Middle Name:
Last Name:KISSINGER
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 1:520 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1490
Mailing Address - Country:US
Mailing Address - Phone:269-427-5811
Mailing Address - Fax:269-427-6107
Practice Address - Street 1:520 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1490
Practice Address - Country:US
Practice Address - Phone:269-427-5811
Practice Address - Fax:269-427-6107
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N12990Medicare ID - Type Unspecified
MIR68664Medicare UPIN