MEDICARE: KYLE A O'DONNELL RPA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	015983	NY
2	363A00000X	Physician Assistant	7586	GA

General Provider Information

NPI Number	:	1801149612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE A O'DONNELL RPA-C

Provider Business Mailing Address
First Line	:	2675 N DECATUR RD STE 512
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-6134
Country	:	US
Telephone Number	:	470-223-4707
Fax Number	:	404-501-7062

Provider Business Practice Location Address
First Line	:	2675 N DECATUR RD STE 512
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30033-6134
Country	:	US
Telephone Number	:	470-223-4707
Fax Number	:	404-501-7062

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2012
Last Update Date	:	11/28/2018

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Directions to “ KYLE A O'DONNELL RPA-C” Practice Location

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