Provider Demographics
NPI:1558454488
Name:DORKOSKIE, KYLE D (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:D
Last Name:DORKOSKIE
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 1:27 ST LAWRENCE DR STE 204
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8312
Mailing Address - Country:US
Mailing Address - Phone:419-455-8570
Mailing Address - Fax:419-455-8579
Practice Address - Street 1:27 ST LAWRENCE DR STE 204
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8312
Practice Address - Country:US
Practice Address - Phone:419-455-8570
Practice Address - Fax:419-455-8579
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01481363A00000X, 363AM0700X
OH50003728363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWV1397AMedicare PIN
WVPA36181Medicare PIN