Provider Demographics
NPI:1417998055
Name:KISH, BRENT PATRICK (PA-C)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:PATRICK
Last Name:KISH
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 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:360-830-1301
Mailing Address - Fax:
Practice Address - Street 1:2200 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7681
Practice Address - Country:US
Practice Address - Phone:360-830-1301
Practice Address - Fax:360-830-1385
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004056363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8398877Medicaid
8920KIOtherREGENCE BLUE SHIELD
P00235352OtherRAILROAD MEDICARE
WA186889OtherLABOR & INDUSTRIES
WA186889OtherLABOR & INDUSTRIES
WAG8804989Medicare PIN
P00235352OtherRAILROAD MEDICARE
P67547Medicare UPIN
WA8398877Medicaid
G8899928Medicare PIN
WAG8804987Medicare PIN
WAG8808543Medicare PIN