Healthcare Provider Details

I. General information

NPI: 1568185171
Provider Name (Legal Business Name): KYLE AUSTIN THAYER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2022
Last Update Date: 10/27/2022
Certification Date: 10/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6655 ALVARADO RD
SAN DIEGO CA
92120-5208
US

IV. Provider business mailing address

25590 PROSPECT AVE APT 46F
LOMA LINDA CA
92354-3156
US

V. Phone/Fax

Practice location:
  • Phone: 619-287-3270
  • Fax:
Mailing address:
  • Phone: 858-414-8254
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License NumberP33910
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: