Provider Demographics
NPI:1780397018
Name:ROTHERHAM, KYLE (PA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:ROTHERHAM
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 1:8005 FARNAM DR STE 305
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-3426
Mailing Address - Country:US
Mailing Address - Phone:402-390-4111
Mailing Address - Fax:402-390-4115
Practice Address - Street 1:8005 FARNAM DR STE 305
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-3426
Practice Address - Country:US
Practice Address - Phone:402-390-4111
Practice Address - Fax:402-390-4115
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1204103363A00000X
NE2867363A00000X
IA118173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant