Provider Demographics
NPI:1760764716
Name:VIDRINE, PATRICK KYLE (PA)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:KYLE
Last Name:VIDRINE
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 1:335 GLESSNER AVE
Mailing Address - Street 2:ATTN: HMG OFFICE
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2269
Mailing Address - Country:US
Mailing Address - Phone:419-520-2379
Mailing Address - Fax:419-520-2824
Practice Address - Street 1:335 GLESSNER AVE
Practice Address - Street 2:ATTN: HMG OFFICE
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-2269
Practice Address - Country:US
Practice Address - Phone:419-520-2379
Practice Address - Fax:419-520-2824
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant