Provider Demographics
NPI:1952731200
Name:WERTZBERGER, KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:WERTZBERGER
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 1:1145 S UTICA AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4013
Mailing Address - Country:US
Mailing Address - Phone:918-579-3825
Mailing Address - Fax:918-579-1262
Practice Address - Street 1:8803 S 101ST EAST AVE STE 100
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-7546
Practice Address - Country:US
Practice Address - Phone:918-579-0220
Practice Address - Fax:918-579-2309
Is Sole Proprietor?:No
Enumeration Date:2013-11-24
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2326363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant