Provider Demographics
NPI:1295885762
Name:SISK, KITTY BONITA (PA-C)
Entity type:Individual
Prefix:MISS
First Name:KITTY
Middle Name:BONITA
Last Name:SISK
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 1:2402 OSLER CT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31707-0205
Mailing Address - Country:US
Mailing Address - Phone:229-438-3300
Mailing Address - Fax:
Practice Address - Street 1:2402 OSLER CT
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31707-0205
Practice Address - Country:US
Practice Address - Phone:229-438-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0100001200AMedicaid
GA970020094OtherRAILROAD MEDICARE
GA97BBGJRMedicare ID - Type Unspecified