Provider Demographics
NPI:1801149612
Name:O'DONNELL, KYLE A (RPA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:A
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2675 N DECATUR RD STE 512
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6134
Mailing Address - Country:US
Mailing Address - Phone:470-223-4707
Mailing Address - Fax:404-501-7062
Practice Address - Street 1:2675 N DECATUR RD STE 512
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-6134
Practice Address - Country:US
Practice Address - Phone:470-223-4707
Practice Address - Fax:404-501-7062
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY015983363A00000X
GA7586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant