Provider Demographics
NPI:1942242904
Name:BROOKS, KYLE THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:THOMAS
Last Name:BROOKS
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 1:3841 GREEN HILLS VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2691
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3601 THE VANDERBILT CLINIC
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37232-0001
Practice Address - Country:US
Practice Address - Phone:615-936-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3519363A00000X, 363AS0400X
AZ3428363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ086785Medicaid
AZ5550830003OtherMEDICARE NSC PEORIA
AZ5550830010OtherMEDICARE NSC GILBERT
AZ5550830007OtherMEDICARE NSC DV
AZ5550830001OtherMEDICARE NSC SCW
AZQ69920Medicare UPIN
AZ086785Medicaid