Provider Demographics
NPI:1265599542
Name:HUMPHREY, KYLE C (PA-C)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:C
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:STE. 280
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-397-3330
Mailing Address - Fax:360-604-1750
Practice Address - Street 1:700 NE 87TH AVE
Practice Address - Street 2:STE. 280
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664
Practice Address - Country:US
Practice Address - Phone:360-397-3330
Practice Address - Fax:360-604-1750
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60030913363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8474041Medicaid
WA8474041Medicaid