Provider Demographics
NPI:1679079586
Name:KISCOE, TIMOTHY G (CRNA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
Last Name:KISCOE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 RELLEUM AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-3805
Mailing Address - Country:US
Mailing Address - Phone:859-803-5302
Mailing Address - Fax:
Practice Address - Street 1:7500 STATE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45255-2439
Practice Address - Country:US
Practice Address - Phone:513-624-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH308963163W00000X
OHAPRN.CRNA.019711367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse