Provider Demographics
NPI:1164170767
Name:BITTNER, KALISSA MADISON (PA-C)
Entity type:Individual
Prefix:
First Name:KALISSA
Middle Name:MADISON
Last Name:BITTNER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:
Practice Address - Street 1:609 N HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-2179
Practice Address - Country:US
Practice Address - Phone:704-772-4700
Practice Address - Fax:704-833-1553
Is Sole Proprietor?:No
Enumeration Date:2022-03-13
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14519363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY8258-5446-1481OtherNATIONAL REGISTRY OF EMERGENCY MEDICAL TECHNICIANS