Provider Demographics
NPI:1730163593
Name:EISAMAN, KELLY J (NPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:EISAMAN
Suffix:
Gender:M
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 AMBERTON PKWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3224
Mailing Address - Country:US
Mailing Address - Phone:214-860-6300
Mailing Address - Fax:
Practice Address - Street 1:9250 AMBERTON PKWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3224
Practice Address - Country:US
Practice Address - Phone:214-860-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX558614363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N9199OtherBLUE CROSS PROV NUMBER
TX8D8879Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
TXQ51356Medicare UPIN