Provider Demographics
NPI:1649278540
Name:BROWN, KYLE R (PA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:BROWN
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 1:31 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3707
Mailing Address - Country:US
Mailing Address - Phone:203-481-5303
Mailing Address - Fax:
Practice Address - Street 1:540 SAYBROOK RD
Practice Address - Street 2:SUITE 160
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4711
Practice Address - Country:US
Practice Address - Phone:860-685-8940
Practice Address - Fax:860-685-8947
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001574363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT747653OtherCONNECTICARE PROVIDER NUM
CT290001574CT01OtherBLUE SHIELD PROVIDER NUMB
CT747653OtherCONNECTICARE PROVIDER NUM
CTQ41333Medicare UPIN