Healthcare Provider Details

I. General information

NPI: 1154617009
Provider Name (Legal Business Name): KYLE DORE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 SOUTH TERRY AVENUE
ORLANDO FL
32805
US

IV. Provider business mailing address

833 CHESTNUT ST STE 520
PHILADELPHIA PA
19107-4430
US

V. Phone/Fax

Practice location:
  • Phone: 844-407-4070
  • Fax: 407-743-3050
Mailing address:
  • Phone: 484-214-6604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116266
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA4195
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: