Provider Demographics
NPI:1609408442
Name:KING, KYLE (PAC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KING
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 W FAIR AVE STE 334
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-5407
Mailing Address - Country:US
Mailing Address - Phone:906-225-4500
Mailing Address - Fax:
Practice Address - Street 1:1414 W FAIR AVE STE 334
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-5407
Practice Address - Country:US
Practice Address - Phone:906-225-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-10
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010252363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant