Provider Demographics
NPI:1013910843
Name:KISH, JOHN C (PA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:C
Last Name:KISH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 FACILITY DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-9438
Mailing Address - Country:US
Mailing Address - Phone:828-452-8110
Mailing Address - Fax:
Practice Address - Street 1:35 FACILITY DRIVE
Practice Address - Street 2:MEDWEST
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721
Practice Address - Country:US
Practice Address - Phone:828-452-5042
Practice Address - Fax:828-452-9225
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS78092Medicare UPIN
NC2763310Medicare ID - Type UnspecifiedJOHN KISH'S MEDICARE #