Provider Demographics
NPI:1538164702
Name:KIERNAN, ROBERT (PA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:KIERNAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-6201
Mailing Address - Country:US
Mailing Address - Phone:619-662-4127
Mailing Address - Fax:
Practice Address - Street 1:950 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-6201
Practice Address - Country:US
Practice Address - Phone:619-662-4127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13891363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP2227Medicare ID - Type Unspecified
MAQ21994Medicare UPIN