Healthcare Provider Details

I. General information

NPI: 1730195165
Provider Name (Legal Business Name): REN BRADFORD KUYKENDALL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 OLYMPIC PLAZA CIR STE 510
TYLER TX
75701-1951
US

IV. Provider business mailing address

PO BOX 9477
TYLER TX
75711-9477
US

V. Phone/Fax

Practice location:
  • Phone: 903-596-3844
  • Fax: 903-596-3843
Mailing address:
  • Phone: 903-594-2450
  • Fax: 903-509-0493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA01442
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: