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General NPI Number Information
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NPI Number | 1053846659
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Entity Type | Individual
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Provider Name | KYLE JERVIS PA-C
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Gender | Male
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Dates
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Enumeration Date | 04/21/2017
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Last Update Date | 06/09/2023
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Provider Practice Location Address
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Address Line | 13677 W MCDOWELL RD # AZ85395
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City | GOODYEAR
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State | AZ
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Zip | 85395-2635
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Country | US
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Telephone | 623-882-1500
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Fax |
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Provider Business Mailing Address
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Address Line | 19947 W RANCHO DR
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City | LITCHFIELD PARK
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State | AZ
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Zip | 85340-2667
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Country | US
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Telephone | 602-740-0131
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 7195
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | C06468
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License Number State | MD
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