Basic Information
| Provider Information | |||||||||
| NPI: | 1730195165 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUYKENDALL | ||||||||
| FirstName: | REN | ||||||||
| MiddleName: | BRADFORD | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9477 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757119477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035942450 | ||||||||
| FaxNumber: | 9035090493 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 OLYMPIC PLAZA CIR | ||||||||
| Address2: | STE 510 | ||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757011951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035963844 | ||||||||
| FaxNumber: | 9035963843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA01442 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.