Provider Demographics
NPI:1942413877
Name:ST. JOHN, KYLE M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:M
Last Name:ST. JOHN
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:PO BOX 22340
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92192-2340
Mailing Address - Country:US
Mailing Address - Phone:619-417-9108
Mailing Address - Fax:
Practice Address - Street 1:3444 KEARNY VILLA RD STE 202
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1960
Practice Address - Country:US
Practice Address - Phone:858-874-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant