Provider Demographics
NPI:1407982689
Name:VIVO, KYLE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:VIVO
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 1:2126 MOZART ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-2246
Mailing Address - Country:US
Mailing Address - Phone:626-674-8109
Mailing Address - Fax:
Practice Address - Street 1:311 WINSTON ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1519
Practice Address - Country:US
Practice Address - Phone:213-893-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18774363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical