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Individual
KYLE D FORTMAN
Active
Individual
KYLE D FORTMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
009532
GA
363A00000X
Physician Assistant
1114
TN
363AM0700X
Medical Physician Assistant
1114
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3379860
—
TN
05
—
3662061
—
TN
01
—
4075854
BCBS TN
TN
Enumeration date
12/18/2006
Last updated
11/18/2019
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