Healthcare Provider Details

I. General information

NPI: 1699745885
Provider Name (Legal Business Name): JENNIFER SHAY KISER PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4611 E SHEA BLVD STE 190
PHOENIX AZ
85028-4259
US

IV. Provider business mailing address

4611 E SHEA BLVD BLDG 3 SUITE 170
PHOENIX AZ
85028-4254
US

V. Phone/Fax

Practice location:
  • Phone: 480-889-0180
  • Fax: 480-889-0186
Mailing address:
  • Phone: 480-889-0180
  • Fax: 480-889-0186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2667
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: