NPIMap

Individual provider Active NPI

Kyle Fetterolf, PA

  • Physician Assistant
  • Kingston, PA
National Provider Identifier
1477529501
Registry record updated Feb 13, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
MA001889L Issued in PA
Practice address
423 3Rd Ave Ste B
Kingston, PA 18704-5809
Phone
(570) 288-3601
Fax
(570) 288-1726
NPI assigned
Feb 28, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 13, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X MA001889L PA Primary

Addresses

Primary practice location

423 3Rd Ave Ste B
Kingston, PA 18704-5809

Mailing address

423 3Rd Ave Ste B
Kingston, PA 18704-5809
Phone (570) 288-3601

Other practice location 1

575 N River St
Wilkes Barre, PA 18764-0999
Phone (570) 270-9192

Other practice location 2

334 Main St
Dickson City, PA 18519-1668
Phone (888) 952-6772

Other practice location 3

677 Kidder St Ste D
Wilkes Barre Township, PA 18702-6914
Phone (570) 825-2046

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address Kyle.fetterolf.1@21771.direct.athenahealth.com

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20070118000165 PA Practitioner - Physician Assistant 2163423195 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 1999
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Commonwealth Physician Network LLCGroup PAC ID 2668696592, 63 clinicians

Practice addresses (Care Compare)

4 E Main St
Nanticoke, PA 18634-1602
Phone (570) 735-7474

423 3Rd Ave
Suite B
Kingston, PA 18704-5809
Phone (570) 288-3601

575 N River St
Wilkes Barre, PA 18702-2634
Phone (570) 552-8938

Hospital & facility affiliations

  • Wilkes-Barre General Hospital Hospital, Wilkes-Barre, PA, CCN 390137
  • Regional Hospital of Scranton Hospital, Scranton, PA, CCN 390237
  • Lehigh Valley Hospital - Hazleton Hospital, Hazleton, PA, CCN 390185

Merit-based Incentive Payment System (MIPS)

Final score
83.3 of 100Reported as group
Quality
74.59
Improvement activities
40

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
MA001889LPAMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Emergency Care Services of Pennsylvania, P.C. Physician Assistant CurrentSince Dec 1, 2006 Accepting new patients
Pennsylvania Physician Services, LLC CurrentSince Feb 8, 2011 Accepting new patients
Medexpress Urgent Care, PC - Pennsylvania CurrentSince Jun 1, 2023 Accepting new patients
Medexpress Urgent Care, PC - Pennsylvania CurrentSince Jun 1, 2023 Accepting new patients
Atlantic Physician Services of Maryland, PC Physician Assistant CurrentSince Feb 15, 2023 Accepting new patients
Emergency Services, PC Past Accepting new patients
Sapphire Emergency Physicians, PC Past Accepting new patients
Emergency Services PC Past Accepting new patients

Locations

4808 Edgmont Ave
Brookhaven, PA 19015
Phone (610) 876-3072

300 Highland Ave
Hanover, PA 17331
Phone (717) 316-3711

7219 McKnight Rd
Ste F
Pittsburgh, PA 15237
Phone (412) 367-3278

2500 Bernville Rd
Reading, PA 19605
Phone (610) 378-2300

334 Main St
Scranton, PA 18519
Phone (570) 307-1767

746 Jefferson Ave
Scranton, PA 18510
Phone (570) 340-5079

575 N River St
Wilkes Barre, PA 18764
Phone (570) 552-1300

575 N River St
Wilkes Barre Township, PA 18702
Phone (570) 283-3222

677 Kidder St
Ste D
Wilkes Barre Township, PA 18702
Phone (570) 825-2046

Interoperability endpoints

  • Direct secure messaging: kfetterolf20795@gohealthupmc.direct-ci.com

Organizations & group practices 13

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

View all 13

Hospital & facility affiliations 5

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1141084800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1739404800000",
    "number": "1477529501",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "423 3RD AVE STE B",
            "city": "KINGSTON",
            "state": "PA",
            "postal_code": "187045809",
            "telephone_number": "570-288-3601",
            "fax_number": "570-288-1726"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "423 3RD AVE STE B",
            "city": "KINGSTON",
            "state": "PA",
            "postal_code": "187045809",
            "telephone_number": "570-288-3601",
            "fax_number": "570-288-1726"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "575 N River St",
            "address_purpose": "LOCATION",
            "city": "Wilkes Barre",
            "state": "PA",
            "postal_code": "187640999",
            "country_code": "US",
            "telephone_number": "570-270-9192",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "334 Main St",
            "address_purpose": "LOCATION",
            "city": "Dickson City",
            "state": "PA",
            "postal_code": "185191668",
            "country_code": "US",
            "telephone_number": "888-952-6772",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "677 Kidder St Ste D",
            "address_purpose": "LOCATION",
            "city": "Wilkes Barre Township",
            "state": "PA",
            "postal_code": "187026914",
            "country_code": "US",
            "telephone_number": "570-825-2046",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FETTEROLF",
        "first_name": "KYLE",
        "credential": "PA",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-02-28",
        "last_updated": "2025-02-13",
        "certification_date": "2025-02-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "PA",
            "license": "MA001889L",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "Kyle.fetterolf.1@21771.direct.athenahealth.com",
            "affiliation": "N",
            "endpointDescription": "AMR direct address",
            "address_1": "423 3rd Ave Ste B",
            "city": "Kingston",
            "state": "PA",
            "country_code": "US",
            "postal_code": "187045809",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Kingston, PA

Sources for this page

Verify at the official NPI Registry.