Provider Demographics
NPI:1720435746
Name:BISTA, BISHAL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BISHAL
Middle Name:
Last Name:BISTA
Suffix:
Gender:M
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 1:315 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67901-2455
Mailing Address - Country:US
Mailing Address - Phone:620-629-6477
Mailing Address - Fax:620-629-6651
Practice Address - Street 1:315 W 15TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2455
Practice Address - Country:US
Practice Address - Phone:620-629-6477
Practice Address - Fax:620-629-6651
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501810363AM0700X
VA0110005992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1501810OtherSTATE LICENSE