Provider Demographics
NPI:1780042952
Name:HEASSLER, KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HEASSLER
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 1:33 CHANDLER AVE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1684
Mailing Address - Country:US
Mailing Address - Phone:585-343-9676
Mailing Address - Fax:
Practice Address - Street 1:33 CHANDLER AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1684
Practice Address - Country:US
Practice Address - Phone:585-343-9676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP00552363A00000X
NY019504363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant