Healthcare Provider Details

I. General information

NPI: 1295331791
Provider Name (Legal Business Name): KYLE MICHAEL SUTHERLAND PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 12/09/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 HANNAH ST
CLEARFIELD PA
16830-1245
US

IV. Provider business mailing address

235 HARRIS AVE
BOALSBURG PA
16827-1239
US

V. Phone/Fax

Practice location:
  • Phone: 814-765-2261
  • Fax:
Mailing address:
  • Phone: 814-409-8652
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1171989
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: