Provider Demographics
NPI:1548720816
Name:JOHNSON, KYLE PATRICK (PA)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:PATRICK
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:KYLE
Other - Middle Name:PATRICK
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:2351 CLAY ST STE 501
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-1931
Mailing Address - Country:US
Mailing Address - Phone:866-898-7148
Mailing Address - Fax:
Practice Address - Street 1:30 MARK WEST SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1436
Practice Address - Country:US
Practice Address - Phone:707-576-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57855363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant