MEDICARE: MISS ERICA LYNN KISH PT, MPT

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	225100000X	Physical Therapist	7806	AZ

General Provider Information

NPI Number	:	1588859789
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ERICA LYNN KISH PT, MPT

Provider Business Mailing Address
First Line	:	PO BOX 100
Second Line	:
City	:	SAINT MICHAELS
State	:	AZ
Zip	:	86511-0100
Country	:	US
Telephone Number	:	928-871-2822
Fax Number	:	928-871-2837

Provider Business Practice Location Address
First Line	:	MUSTANG ROAD, 1 MILE NORTH OF RT 264
Second Line	:
City	:	SAINT MICHAELS
State	:	AZ
Zip	:	86511-0100
Country	:	US
Telephone Number	:	928-871-2822
Fax Number	:	928-871-2837

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

Provider Enumeration Date	:	09/11/2007
Last Update Date	:	09/11/2007

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