Provider Demographics
NPI:1629489430
Name:SMALL, KAYLA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KAYLA
Middle Name:ELIZABETH
Last Name:SMALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:KAYLA
Other - Middle Name:ELIZABETH
Other - Last Name:MCKINNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148
Mailing Address - Country:US
Mailing Address - Phone:508-250-6386
Mailing Address - Fax:
Practice Address - Street 1:1493 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139
Practice Address - Country:US
Practice Address - Phone:617-665-2113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5103363A00000X
MA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5400299032Medicare PIN