Provider Demographics
NPI:1932548443
Name:SMITH, KYLIE KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:KATHLEEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 S RAYMOND AVE UNIT 330
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3206
Mailing Address - Country:US
Mailing Address - Phone:626-793-8194
Mailing Address - Fax:626-793-3664
Practice Address - Street 1:630 S RAYMOND AVE UNIT 330
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3206
Practice Address - Country:US
Practice Address - Phone:626-793-8194
Practice Address - Fax:626-793-3664
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23036363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1689740805Medicare PIN