Provider Demographics
NPI:1508491812
Name:GUDERIAN, KYLE (NP)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GUDERIAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 HUNTS LANDING DR
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-4125
Mailing Address - Country:US
Mailing Address - Phone:478-235-0963
Mailing Address - Fax:
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-722-9011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-06
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN258791363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN258791OtherGEORGIA NURSING BOARD