Provider Demographics
NPI:1699745885
Name:KISER, JENNIFER SHAY (PAC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SHAY
Last Name:KISER
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4611 E SHEA BLVD
Mailing Address - Street 2:BLDG 3 SUITE 170
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-4254
Mailing Address - Country:US
Mailing Address - Phone:480-889-0180
Mailing Address - Fax:480-889-0186
Practice Address - Street 1:4611 E SHEA BLVD STE 190
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-4259
Practice Address - Country:US
Practice Address - Phone:480-889-0180
Practice Address - Fax:480-889-0186
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2667363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ738320Medicaid
P60232Medicare UPIN
AZ738320Medicaid