Provider Demographics
NPI:1932574381
Name:HOLLENBACK, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:HOLLENBACK
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 1:486 W 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:GLENNS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83623-2701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2280 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3142
Practice Address - Country:US
Practice Address - Phone:208-587-3988
Practice Address - Fax:208-587-3324
Is Sole Proprietor?:No
Enumeration Date:2015-12-10
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1330363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical