Basic Information
| Provider Information | |||||||||
| NPI: | 1649278540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRANFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064053707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034815303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 540 SAYBROOK RD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574711 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606858940 | ||||||||
| FaxNumber: | 8606858947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 363AS0400X | 001574 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 747653 | 01 | CT | CONNECTICARE PROVIDER NUM | OTHER | 290001574CT01 | 01 | CT | BLUE SHIELD PROVIDER NUMB | OTHER |