Basic Information
| Provider Information | |||||||||
| NPI: | 1598828923 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTMAN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1968 PEACHTREE RD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043673014 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1968 PEACHTREE RD NW | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303091281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4043673014 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2006 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1114 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 1114 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 009532 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3379860 | 05 | TN | MEDICAID | 3662061 | 05 | TN | MEDICAID | 4075854 | 01 | TN | BCBS TN | OTHER |