Provider Demographics
NPI:1881996254
Name:BROUGH, KYLIE A (PAC)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:A
Last Name:BROUGH
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1950 BLUEGRASS CIR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-7323
Mailing Address - Country:US
Mailing Address - Phone:307-778-2860
Mailing Address - Fax:307-778-2860
Practice Address - Street 1:1950 BLUEGRASS CIR
Practice Address - Street 2:SUITE 170
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-7323
Practice Address - Country:US
Practice Address - Phone:307-778-2860
Practice Address - Fax:307-778-2860
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WYTL506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant