Provider Demographics
NPI:1346714946
Name:RUDOLPH, KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:M
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 1:3823 W PAWNEE RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1343
Mailing Address - Country:US
Mailing Address - Phone:808-861-2423
Mailing Address - Fax:
Practice Address - Street 1:CAMP CASEY
Practice Address - Street 2:0037 FA BN 06 FIELD ARTIL
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96224-5543
Practice Address - Country:US
Practice Address - Phone:808-861-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1158131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant