Provider Demographics
NPI:1982786380
Name:COOPER, KYLE GENE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:GENE
Last Name:COOPER
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 1:9 VIERVILLE CIR
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-8504
Mailing Address - Country:US
Mailing Address - Phone:850-882-1170
Mailing Address - Fax:850-882-1194
Practice Address - Street 1:6069 WALKERS LN
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-8505
Practice Address - Country:US
Practice Address - Phone:850-882-1208
Practice Address - Fax:850-882-1194
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant