Healthcare Provider Details

I. General information

NPI: 1902463391
Provider Name (Legal Business Name): KYLE DAVID RAY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR BLDG 830
WRIGHT PAT OH
45433-5529
US

IV. Provider business mailing address

101 BODIN CIR
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 708-261-8215
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: