Healthcare Provider Details

I. General information

NPI: 1154326676
Provider Name (Legal Business Name): DENNIS KIESEL P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 N ARLINGTON AVE
RENO NV
89503-4723
US

IV. Provider business mailing address

1000 E 1ST ST STE 404
DULUTH MN
55805-2297
US

V. Phone/Fax

Practice location:
  • Phone: 775-786-3040
  • Fax: 775-786-1386
Mailing address:
  • Phone: 775-786-3040
  • Fax: 775-786-1386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9794
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1490
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA1490
License Number StateNV
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1490
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: