Provider Demographics
NPI:1083251011
Name:SULZER, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SULZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 E. NEW YORK AVE
Mailing Address - Street 2:4TH FLOOR ADMIN
Mailing Address - City:SOMERS POINT
Mailing Address - State:NJ
Mailing Address - Zip Code:08244
Mailing Address - Country:US
Mailing Address - Phone:609-653-3265
Mailing Address - Fax:609-926-4311
Practice Address - Street 1:649 SHORE RD
Practice Address - Street 2:
Practice Address - City:SOMERS POINT
Practice Address - State:NJ
Practice Address - Zip Code:08244-2449
Practice Address - Country:US
Practice Address - Phone:609-365-6239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-10
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00554800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0754536Medicaid