Provider Demographics
NPI:1164494019
Name:PARKS, KYLE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:PARKS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 CORAL RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:CORALVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52241-4708
Mailing Address - Country:US
Mailing Address - Phone:319-665-6730
Mailing Address - Fax:319-665-6721
Practice Address - Street 1:2700 CORAL RIDGE AVE
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-4708
Practice Address - Country:US
Practice Address - Phone:319-665-6730
Practice Address - Fax:319-665-6721
Is Sole Proprietor?:No
Enumeration Date:2006-02-05
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001526363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1164494019Medicaid
IAI16944Medicare PIN
IA1164494019Medicaid