Provider Demographics
NPI:1619449410
Name:CLOVER, KYLE J (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:J
Last Name:CLOVER
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 1:37700 FRISCHHOLZ CT
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20659-2656
Mailing Address - Country:US
Mailing Address - Phone:240-925-2764
Mailing Address - Fax:
Practice Address - Street 1:14090 HG TRUEMAN RD
Practice Address - Street 2:
Practice Address - City:SOLOMONS
Practice Address - State:MD
Practice Address - Zip Code:20688-3151
Practice Address - Country:US
Practice Address - Phone:410-394-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007078363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant