Healthcare Provider Details

I. General information

NPI: 1700826419
Provider Name (Legal Business Name): KYLE EVAN HOLLINGSWORTH PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 S WALKER AVE BLDG A
OKLAHOMA CITY OK
73139-9475
US

IV. Provider business mailing address

8100 S WALKER AVE BLDG A
OKLAHOMA CITY OK
73139-9475
US

V. Phone/Fax

Practice location:
  • Phone: 405-632-4468
  • Fax: 405-632-0436
Mailing address:
  • Phone: 405-632-4468
  • Fax: 405-632-0436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1341
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1341
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1341
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: