Provider Demographics
NPI:1437610268
Name:HUMBERTSON, KYLIE ALLISON (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:ALLISON
Last Name:HUMBERTSON
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 1:903 HUNTINGDON AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15522-1046
Mailing Address - Country:US
Mailing Address - Phone:301-268-2672
Mailing Address - Fax:
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4804
Practice Address - Country:US
Practice Address - Phone:814-889-6157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060689363A00000X
PAOA004853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant