Provider Demographics
NPI:1396290185
Name:GRIFFIN, KYLE (PA-C, MPH, ATC)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GRIFFIN
Suffix:
Gender:M
Credentials:PA-C, MPH, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6427 WESTLAKE DR
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:MI
Mailing Address - Zip Code:49730-9731
Mailing Address - Country:US
Mailing Address - Phone:770-655-6435
Mailing Address - Fax:
Practice Address - Street 1:2922 D AND M DR STE B
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-7417
Practice Address - Country:US
Practice Address - Phone:231-348-3283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260025982255A2300X
MI5601010798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer