Provider Demographics
NPI:1386253706
Name:MACE, KYLE MATTHEW (PA-S)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:MATTHEW
Last Name:MACE
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746450
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6450
Mailing Address - Country:US
Mailing Address - Phone:251-434-3626
Mailing Address - Fax:251-445-2464
Practice Address - Street 1:2451 UNIVERSITY HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36617-2300
Practice Address - Country:US
Practice Address - Phone:251-471-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA.1865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty