Provider Demographics
NPI:1295760486
Name:SLOAN, KYLE ANN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KYLE
Middle Name:ANN
Last Name:SLOAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KYLE
Other - Middle Name:ANN
Other - Last Name:RUTKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6038 RIVER BIRCH COURT
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076
Mailing Address - Country:US
Mailing Address - Phone:443-610-3794
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC02954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ32563Medicare UPIN
MDS806K340Medicare ID - Type Unspecified