Provider Demographics
NPI:1750567129
Name:KIESECKER, ROBERT ANTHONY JR (DNP, FNP-BC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ANTHONY
Last Name:KIESECKER
Suffix:JR
Gender:M
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5987
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:781 BLACK OAK DR STE 102
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9501
Practice Address - Country:US
Practice Address - Phone:541-789-4236
Practice Address - Fax:541-789-5965
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2889363L00000X
WAAP60681430363L00000X
OR201909324NP-PP363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ405773Medicaid
WA1750567129Medicaid
AZZ197493OtherMEDICARE
OR201909324NP-PPOtherOR NP LICENSE
AZAP2889OtherAZ LICENSE
WAP01708343OtherRR MEDICARE WVH