=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184239949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE HARDEN PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2020
-----------------------------------------------------
Last Update Date | 10/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13127 VAIL RIDGE DR
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33579-7196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-661-6199
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1085 LAKE IRENE RD
-----------------------------------------------------
City | CASSELBERRY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32707-2547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-335-2405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 9113509
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------