Provider Demographics
NPI:1598304636
Name:GORTAT, KYLE E (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:E
Last Name:GORTAT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7125 ORCHARD LAKE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3616
Mailing Address - Country:US
Mailing Address - Phone:248-865-7444
Mailing Address - Fax:
Practice Address - Street 1:7125 ORCHARD LAKE RD STE 100
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3616
Practice Address - Country:US
Practice Address - Phone:248-865-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant