Provider Demographics
NPI:1629001649
Name:PATCH, KYRUS (PA)
Entity Type:Individual
Prefix:
First Name:KYRUS
Middle Name:
Last Name:PATCH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 GRAND CANAL DR
Mailing Address - Street 2:
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34110-1506
Mailing Address - Country:US
Mailing Address - Phone:239-598-1899
Mailing Address - Fax:
Practice Address - Street 1:1279 GRAND CANAL DR
Practice Address - Street 2:
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34110-1506
Practice Address - Country:US
Practice Address - Phone:239-598-1899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA0001573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAS56613Medicare UPIN