Provider Demographics
NPI:1043940620
Name:LISKE, KACIE RIANNE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KACIE
Middle Name:RIANNE
Last Name:LISKE
Suffix:
Gender:F
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 1:601 W DAVENPORT ST
Mailing Address - Street 2:
Mailing Address - City:ELDRIDGE
Mailing Address - State:IA
Mailing Address - Zip Code:52748-1168
Mailing Address - Country:US
Mailing Address - Phone:563-343-0395
Mailing Address - Fax:
Practice Address - Street 1:601 W DAVENPORT ST
Practice Address - Street 2:
Practice Address - City:ELDRIDGE
Practice Address - State:IA
Practice Address - Zip Code:52748-1168
Practice Address - Country:US
Practice Address - Phone:563-343-0395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-15
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA114799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant