Provider Demographics
NPI:1386046878
Name:KISTER, JOSEPH ANTHONY (AA-C)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:KISTER
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Gender:M
Credentials:AA-C
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Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6000
Practice Address - Fax:636-386-7679
Is Sole Proprietor?:No
Enumeration Date:2014-09-16
Last Update Date:2019-09-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2014032277367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1386046878Medicaid
MO132300606Medicare PIN
MO132680736Medicare PIN