MEDICARE: SHANE TRAVIS KISER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA2034	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PA2034	OTHER	KY	KY MEDICAL LICENSE

General Provider Information

NPI Number	:	1003286709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANE TRAVIS KISER PA-C

Provider Business Mailing Address
First Line	:	250 KISER CEM RD
Second Line	:
City	:	OLIVE HILL
State	:	KY
Zip	:	41164-9809
Country	:	US
Telephone Number	:	606-780-5500
Fax Number	:	606-783-7281

Provider Business Practice Location Address
First Line	:	250 KISER CEM RD
Second Line	:
City	:	OLIVE HILL
State	:	KY
Zip	:	41164-9809
Country	:	US
Telephone Number	:	606-780-5500
Fax Number	:	606-783-7281

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2015
Last Update Date	:	10/10/2025

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