Healthcare Provider Details

I. General information

NPI: 1013910843
Provider Name (Legal Business Name): JOHN C KISH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 FACILITY DRIVE MEDWEST
CLYDE NC
28721
US

IV. Provider business mailing address

35 FACILITY DR
CLYDE NC
28721-9438
US

V. Phone/Fax

Practice location:
  • Phone: 828-452-5042
  • Fax: 828-452-9225
Mailing address:
  • Phone: 828-452-8110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103183
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: