Provider Demographics
NPI:1295459923
Name:BORDEN, KYLE STEPHEN (PA-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:STEPHEN
Last Name:BORDEN
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 1:101 LAKE AVE APT 2004
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-3045
Mailing Address - Country:US
Mailing Address - Phone:321-276-5619
Mailing Address - Fax:
Practice Address - Street 1:101 LAKE AVE APT 2004
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-3045
Practice Address - Country:US
Practice Address - Phone:321-276-5619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-27
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant