Provider Demographics
NPI:1821639451
Name:HARRIS, KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HARRIS
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 1:2884 WELLNESS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8427
Mailing Address - Country:US
Mailing Address - Phone:386-668-2221
Mailing Address - Fax:
Practice Address - Street 1:2884 WELLNESS AVE STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763
Practice Address - Country:US
Practice Address - Phone:386-668-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2020-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9112709207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant