Healthcare Provider Details

I. General information

NPI: 1184239949
Provider Name (Legal Business Name): KYLE HARDEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13127 VAIL RIDGE DR
RIVERVIEW FL
33579-7196
US

IV. Provider business mailing address

1085 LAKE IRENE RD
CASSELBERRY FL
32707-2547
US

V. Phone/Fax

Practice location:
  • Phone: 813-661-6199
  • Fax:
Mailing address:
  • Phone: 832-335-2405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9113509
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: