Provider Demographics
NPI:1083306161
Name:BLACKSHEAR, KYLA RENAE (PA-S)
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:RENAE
Last Name:BLACKSHEAR
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 RUTLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-8385
Mailing Address - Country:US
Mailing Address - Phone:314-359-0188
Mailing Address - Fax:
Practice Address - Street 1:1601 HARMON AVE.
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314
Practice Address - Country:US
Practice Address - Phone:912-435-5924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant