Provider Demographics
NPI:1417341405
Name:KENYON, KYLE JUDSON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JUDSON
Last Name:KENYON
Suffix:
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:288 S RIDGECREST AVE
Mailing Address - Street 2:DLP RUTHERFORD PHYSICIAN PRACTICES, LLC
Mailing Address - City:RUTHERFORDTON
Mailing Address - State:NC
Mailing Address - Zip Code:28139-2838
Mailing Address - Country:US
Mailing Address - Phone:828-286-5572
Mailing Address - Fax:
Practice Address - Street 1:197 PLAZA DR
Practice Address - Street 2:THE CLINIC AT WALMART
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-3712
Practice Address - Country:US
Practice Address - Phone:828-286-9438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-05653363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical