Healthcare Provider Details

I. General information

NPI: 1386760510
Provider Name (Legal Business Name): HARRISON SHERMAN KUYKENDALL III P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12550 HESPERIA ROAD SUITE 100
VICTORVILLE CA
92395-0000
US

IV. Provider business mailing address

17095 MAIN ST
HESPERIA CA
92345-0000
US

V. Phone/Fax

Practice location:
  • Phone: 760-241-6666
  • Fax: 760-241-7575
Mailing address:
  • Phone: 760-241-6666
  • Fax: 760-241-7575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11476
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: