Provider Demographics
NPI:1225486442
Name:SUTHERLAND, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SUTHERLAND
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 1:3219 E CAMELBACK RD
Mailing Address - Street 2:#205
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-2307
Mailing Address - Country:US
Mailing Address - Phone:480-388-1742
Mailing Address - Fax:
Practice Address - Street 1:3219 E CAMELBACK RD
Practice Address - Street 2:#205
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-2307
Practice Address - Country:US
Practice Address - Phone:480-388-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ6666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program