Basic Information
Provider Information | |||||||||
NPI: | 1295903342 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HORNER | ||||||||
FirstName: | KYLE | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 HOLLYMONT DR | ||||||||
Address2: |   | ||||||||
City: | HOLLY SPRINGS | ||||||||
State: | NC | ||||||||
PostalCode: | 275405965 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3175083950 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2800 BLUE RIDGE RD STE 400 | ||||||||
Address2: |   | ||||||||
City: | RALEIGH | ||||||||
State: | NC | ||||||||
PostalCode: | 276076477 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197875380 | ||||||||
FaxNumber: | 9197873415 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/12/2008 | ||||||||
LastUpdateDate: | 04/21/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | PA9104485 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 0010-06049 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 230482 | 01 | FL | AMERIGROUP | OTHER | 33803A | 01 |   | GROUP MEDICARE NUMBER | OTHER |