Provider Demographics
NPI:1942755699
Name:ROBERTSON, KAYLA M (PA-C)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:M
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:200 E CHESTNUT ST
Practice Address - Street 2:SERVICE BUILDING, SUITE 303
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1831
Practice Address - Country:US
Practice Address - Phone:502-629-5552
Practice Address - Fax:502-629-3132
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2167363AM0700X
KYAPPLIED363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100436050Medicaid
KYK229490OtherMEDICARE