Provider Demographics
NPI:1922768860
Name:WHITE, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6511 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:NEW LOTHROP
Mailing Address - State:MI
Mailing Address - Zip Code:48460-9716
Mailing Address - Country:US
Mailing Address - Phone:810-247-3892
Mailing Address - Fax:
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-464-3353
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-20
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA61705363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA61705OtherPHYSICIAN ASSISTANT BOARD OF CALIFORNIA