Provider Demographics
NPI:1780770057
Name:NIE, KERRY KUNRONG (PA-C)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:KUNRONG
Last Name:NIE
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 1:30 E APPLE ST
Mailing Address - Street 2:STE 1480
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2939
Mailing Address - Country:US
Mailing Address - Phone:937-208-3220
Mailing Address - Fax:937-208-3633
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:STE 1480
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-3220
Practice Address - Fax:937-208-3633
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002031363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0110876Medicaid
OHNIPA26021Medicare ID - Type Unspecified
OHH380950Medicare PIN
NIPA26023Medicare PIN
OH0110876Medicaid
NIPA26022Medicare PIN