Provider Demographics
NPI:1245738038
Name:WOOLEY, KYLA MEGAN (PA)
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:MEGAN
Last Name:WOOLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KYLA
Other - Middle Name:MEGAN
Other - Last Name:BYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2619 W FAIRVIEW AVE STE 2100
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6722
Practice Address - Country:US
Practice Address - Phone:208-706-2663
Practice Address - Fax:208-489-4300
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018002195363A00000X
IDPA-1906363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220051491Medicaid