Provider Demographics
NPI:1750055695
Name:SMITH, KYLE (PA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 MCNAUGHTEN RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43213-2174
Mailing Address - Country:US
Mailing Address - Phone:614-627-2000
Mailing Address - Fax:740-383-7097
Practice Address - Street 1:85 MCNAUGHTEN RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43213-2174
Practice Address - Country:US
Practice Address - Phone:614-627-2000
Practice Address - Fax:740-383-7097
Is Sole Proprietor?:No
Enumeration Date:2021-08-04
Last Update Date:2023-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.006917363AS0400X
OH363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant