Provider Demographics
NPI:1518292952
Name:BROWN, KYLE DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DANIEL
Last Name:BROWN
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 744786
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4786
Mailing Address - Country:US
Mailing Address - Phone:704-834-2450
Mailing Address - Fax:704-671-5331
Practice Address - Street 1:700 N MAIN ST
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164-1438
Practice Address - Country:US
Practice Address - Phone:704-263-8945
Practice Address - Fax:704-263-2591
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02413363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1518292952Medicaid
SC1138PAMedicaid
NC8101715Medicaid
NCNC2102EMedicare PIN
NC8101715Medicaid
SC1138PAMedicaid
NCNC2102DMedicare PIN
NCNC2102GMedicare PIN
NCNC2102HMedicare PIN
NC2762555Medicare PIN
NCNC2102CMedicare PIN