Provider Demographics
NPI:1205117520
Name:KANESHIRO, ALISON G (NP)
Entity type:Individual
Prefix:
First Name:ALISON
Middle Name:G
Last Name:KANESHIRO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1528
Mailing Address - Country:US
Mailing Address - Phone:574-753-7541
Mailing Address - Fax:
Practice Address - Street 1:1101 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1528
Practice Address - Country:US
Practice Address - Phone:574-753-7541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005293A363L00000X
IL209009028363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001042126OtherANTHEM
INP01756393OtherRAILROAD MEDICARE
IN201378490Medicaid
IN000001042126OtherANTHEM
INP01756393OtherRAILROAD MEDICARE