Provider Demographics
NPI:1861731044
Name:KISNER, BRIAN SCOTT (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:KISNER
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 1:1717 N E ST
Mailing Address - Street 2:SUITE422
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32501-6339
Mailing Address - Country:US
Mailing Address - Phone:850-469-0642
Mailing Address - Fax:850-437-8318
Practice Address - Street 1:1717 N E ST
Practice Address - Street 2:SUITE422
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6339
Practice Address - Country:US
Practice Address - Phone:850-469-0642
Practice Address - Fax:850-437-8318
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109718363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019010700Medicaid
FL82TJYOtherBCBS