Provider Demographics
NPI:1518704030
Name:KISALA, KACPER (PA-C)
Entity type:Individual
Prefix:
First Name:KACPER
Middle Name:
Last Name:KISALA
Suffix:
Gender:M
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 1:14 SAM WEST RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077-9734
Mailing Address - Country:US
Mailing Address - Phone:413-250-1604
Mailing Address - Fax:
Practice Address - Street 1:148 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4520
Practice Address - Country:US
Practice Address - Phone:860-763-7650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6665363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical