Healthcare Provider Details

I. General information

NPI: 1215067541
Provider Name (Legal Business Name): JASON KYLE HONAKER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10500 LIGON MILL RD STE 113
WAKE FOREST NC
27587-4576
US

IV. Provider business mailing address

PO BOX 60447 SUITE 4K
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 919-570-5705
  • Fax:
Mailing address:
  • Phone: 910-721-4100
  • Fax: 910-721-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-05410
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002364
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number014724
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: