Provider Demographics
NPI:1295903342
Name:HORNER, KYLE D (PA-C)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:D
Last Name:HORNER
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 1:1000 HOLLYMONT DR
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:NC
Mailing Address - Zip Code:27540-5965
Mailing Address - Country:US
Mailing Address - Phone:317-508-3950
Mailing Address - Fax:
Practice Address - Street 1:2800 BLUE RIDGE RD STE 400
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6477
Practice Address - Country:US
Practice Address - Phone:919-787-5380
Practice Address - Fax:919-787-3415
Is Sole Proprietor?:No
Enumeration Date:2008-02-12
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104485363AS0400X
NC0010-06049363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL230482OtherAMERIGROUP
33803AOtherGROUP MEDICARE NUMBER