Provider Demographics
NPI:1467475657
Name:DEUTER, KYLE STEVEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:STEVEN
Last Name:DEUTER
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:PO BOX 1334
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31598-1334
Mailing Address - Country:US
Mailing Address - Phone:912-427-0800
Mailing Address - Fax:912-427-6029
Practice Address - Street 1:110 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0044
Practice Address - Country:US
Practice Address - Phone:912-427-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00080100363AS0400X
GA007290363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ066499PFCMedicare PIN
NJP00452805Medicare PIN
P51786Medicare UPIN