Provider Demographics
NPI:1144829425
Name:RICKARDS, KYLE JOSEPH (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:JOSEPH
Last Name:RICKARDS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1821 HILLANDALE RD STE 24A
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-2671
Mailing Address - Country:US
Mailing Address - Phone:919-383-4355
Mailing Address - Fax:
Practice Address - Street 1:1821 HILLANDALE RD STE 24A
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2671
Practice Address - Country:US
Practice Address - Phone:919-383-4355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10670363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant