Healthcare Provider Details

I. General information

NPI: 1215552591
Provider Name (Legal Business Name): RYAN WILGUS KISSINGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE
JBER AK
99506-3702
US

IV. Provider business mailing address

5955 ZEAMER AVE
JBER AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-2602
  • Fax:
Mailing address:
  • Phone: 907-580-2602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25785
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: