Provider Demographics
NPI:1285602847
Name:CONROD, KYLE AARON (PA-C, ATC/L)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:AARON
Last Name:CONROD
Suffix:
Gender:M
Credentials:PA-C, ATC/L
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Mailing Address - Street 1:2325 DOUGHERTY FERRY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3356
Mailing Address - Country:US
Mailing Address - Phone:314-909-1359
Mailing Address - Fax:
Practice Address - Street 1:2325 DOUGHERTY FERRY RD
Practice Address - Street 2:STE 100
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3356
Practice Address - Country:US
Practice Address - Phone:314-909-1359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0022512255A2300X
IL085004280363A00000X
MO2012013844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer