Provider Demographics
NPI:1811361397
Name:CALLAHAN, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:CALLAHAN
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 1:735 S ROBIN WAY
Mailing Address - Street 2:
Mailing Address - City:SATELLITE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937-3459
Mailing Address - Country:US
Mailing Address - Phone:863-529-3613
Mailing Address - Fax:
Practice Address - Street 1:735 S ROBIN WAY
Practice Address - Street 2:
Practice Address - City:SATELLITE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-3459
Practice Address - Country:US
Practice Address - Phone:863-529-3613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant