Provider Demographics
NPI:1316411796
Name:MATHIS, KYLE NEWTON (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:NEWTON
Last Name:MATHIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:844-266-8268
Mailing Address - Fax:
Practice Address - Street 1:1420 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5160
Practice Address - Country:US
Practice Address - Phone:704-289-8427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-18
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-08861363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant