Provider Demographics
NPI:1619164985
Name:REDWOOD, KYLA BARAJAS (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLA
Middle Name:BARAJAS
Last Name:REDWOOD
Suffix:
Gender:F
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 1:1201 CORNERSTONE CT
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-1860
Mailing Address - Country:US
Mailing Address - Phone:207-576-2900
Mailing Address - Fax:
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511
Practice Address - Country:US
Practice Address - Phone:203-789-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001976363A00000X
NC0010-01451363A00000X
CT1976363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235900Medicaid