Provider Demographics
NPI:1144773151
Name:LANDIS, KYLE (PA)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:
Last Name:LANDIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705-1143
Mailing Address - Country:US
Mailing Address - Phone:570-821-1100
Mailing Address - Fax:570-821-1108
Practice Address - Street 1:200 S RIVER ST
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1143
Practice Address - Country:US
Practice Address - Phone:570-821-1100
Practice Address - Fax:570-821-1108
Is Sole Proprietor?:No
Enumeration Date:2016-07-26
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA058329363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPENDINGOtherMEDICARE ID