Provider Demographics
NPI:1982974556
Name:STOTT, KYLIE (PA-C)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:STOTT
Suffix:
Gender:F
Credentials:PA-C
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 13955
Mailing Address - Street 2:#A
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29422-3955
Mailing Address - Country:US
Mailing Address - Phone:843-795-5362
Mailing Address - Fax:843-795-1921
Practice Address - Street 1:418 FOLLY RD
Practice Address - Street 2:#A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2625
Practice Address - Country:US
Practice Address - Phone:843-795-5362
Practice Address - Fax:843-795-1921
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03320363A00000X
SC1804363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2530PAMedicaid
NC8101889Medicaid
NCNC5273BMedicare PIN
NCNC5273JMedicare PIN
NCNC5273EMedicare PIN
NCNC5273DMedicare PIN
NCNC5273GMedicare PIN
NCNC5273FMedicare PIN
NCNC5273HMedicare PIN
NCNC5273KMedicare PIN
SC2530PAMedicaid
NC8101889Medicaid
SCSC0008A634Medicare PIN
NCNC52731Medicare PIN