Healthcare Provider Details

I. General information

NPI: 1518972496
Provider Name (Legal Business Name): KYLE T YANDLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2006
Last Update Date: 03/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2878 FIVE FORKS TRICKUM RD STE 2A
LAWRENCEVILLE GA
30044-5896
US

IV. Provider business mailing address

106 BROAD ST APT 1632
LOGANVILLE GA
30052-7463
US

V. Phone/Fax

Practice location:
  • Phone: 678-344-8700
  • Fax: 678-344-8600
Mailing address:
  • Phone: 678-635-8130
  • Fax: 678-635-8131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004390
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: