Basic Information
| Provider Information | |||||||||
| NPI: | 1659316123 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIESTER | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837778 | ||||||||
| FaxNumber: | 7403758118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 DELAWARE AVE | ||||||||
| Address2: | |||||||||
| City: | MARION | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433026416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403837778 | ||||||||
| FaxNumber: | 7403758118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | NA06849 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | COA.06849-NA | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2299187 | 05 | OH | MEDICAID |