Provider Demographics
NPI:1003584608
Name:KYLE, TRAVIS ANDREW (PA)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:ANDREW
Last Name:KYLE
Suffix:
Gender:M
Credentials:PA
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 2078
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6156
Mailing Address - Country:US
Mailing Address - Phone:940-626-8810
Mailing Address - Fax:940-626-8811
Practice Address - Street 1:2301 S FM 51 STE 100
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3864
Practice Address - Country:US
Practice Address - Phone:940-626-8810
Practice Address - Fax:940-626-8811
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8QG973OtherBCBS
TX430462801Medicaid