Provider Demographics
NPI:1700426343
Name:KISER, MIKAELA (PA)
Entity Type:Individual
Prefix:
First Name:MIKAELA
Middle Name:
Last Name:KISER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3813 STAUNTON AVE SE UNIT A
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1537
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13682 APPALACHIAN HWY
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:WV
Practice Address - Zip Code:26260-8299
Practice Address - Country:US
Practice Address - Phone:304-259-7828
Practice Address - Fax:304-259-5703
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-12
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty