Provider Demographics
NPI:1841739141
Name:VAUGHN, KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:VAUGHN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4445 CORPORATION LN STE 100
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-3666
Mailing Address - Country:US
Mailing Address - Phone:757-623-0005
Mailing Address - Fax:757-548-1128
Practice Address - Street 1:814 KEMPSVILLE RD STE 102
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4001
Practice Address - Country:US
Practice Address - Phone:757-623-0005
Practice Address - Fax:757-389-5412
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-07079363AM0700X
VA0110007161363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical