Provider Demographics
NPI:1467866582
Name:LAFARGE, KYLE HAYDEN
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:HAYDEN
Last Name:LAFARGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5574 S BETHEL LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-9473
Mailing Address - Country:US
Mailing Address - Phone:573-356-2242
Mailing Address - Fax:
Practice Address - Street 1:1020 HITT STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201
Practice Address - Country:US
Practice Address - Phone:573-882-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO130671260005364SC2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC2300XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistChronic Care