Provider Demographics
NPI:1932133618
Name:KISUCKY, PAUL III (CRNA)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:KISUCKY
Suffix:III
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX583176367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
00C79MOtherBCBS OF TEXAS
TX088570904Medicaid
TX088570902Medicaid
TX84581UOtherBCBS
86378UOtherBCBS OF TEXAS
TX088570904Medicaid
TX8F1561Medicare PIN
TX84581UOtherBCBS
P00087960Medicare PIN
TX8D1825Medicare PIN
TXP00162199Medicare PIN
TX00035CMedicare PIN
NM349710001Medicare PIN