Provider Demographics
NPI:1477844116
Name:KISNER, KRISTOFER
Entity type:Individual
Prefix:
First Name:KRISTOFER
Middle Name:
Last Name:KISNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 W SULPHUR ST
Mailing Address - Street 2:STE. B-2
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-3703
Mailing Address - Country:US
Mailing Address - Phone:951-454-2673
Mailing Address - Fax:951-344-1749
Practice Address - Street 1:119 W SULPHUR ST
Practice Address - Street 2:STE. B-2
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-3703
Practice Address - Country:US
Practice Address - Phone:951-454-2673
Practice Address - Fax:951-344-1749
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA201418017OtherWORKCOMP