Provider Demographics
NPI:1548976962
Name:RUNYON, CALEB TYLER (PA-C)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:TYLER
Last Name:RUNYON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2831 PIEDMONT RIVER WAY
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-7403
Mailing Address - Country:US
Mailing Address - Phone:859-324-0138
Mailing Address - Fax:
Practice Address - Street 1:3200 BLUE RIDGE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-8086
Practice Address - Country:US
Practice Address - Phone:919-781-1437
Practice Address - Fax:919-787-4870
Is Sole Proprietor?:No
Enumeration Date:2023-01-30
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-13473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program