Provider Demographics
NPI:1417324344
Name:TANABE, KYLIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:TANABE
Suffix:
Gender:F
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 1:24 STEVENS ST
Mailing Address - Street 2:BUILDING 2, 4C
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06850-3852
Mailing Address - Country:US
Mailing Address - Phone:203-852-2188
Mailing Address - Fax:
Practice Address - Street 1:40 PROSPECT AVE
Practice Address - Street 2:BUILDING 2, 4C
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3737
Practice Address - Country:US
Practice Address - Phone:207-671-0235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3407363A00000X, 363AS0400X
CA54130363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant