Healthcare Provider Details

I. General information

NPI: 1629239413
Provider Name (Legal Business Name): NATHANIEL LLOYD KISTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 12/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MACCORKLE AVE SE SUITE 301
CHARLESTON WV
25304-1223
US

IV. Provider business mailing address

3100 MACCORKLE SEAVE 301
CHARLESTON WV
25304-1229
US

V. Phone/Fax

Practice location:
  • Phone: 304-388-5395
  • Fax: 304-388-5398
Mailing address:
  • Phone: 304-388-5395
  • Fax: 304-388-5398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License Number28368
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: