Provider Demographics
NPI:1861896300
Name:TEMPORAL, KAYLIE ALEXANDRA (PA)
Entity type:Individual
Prefix:
First Name:KAYLIE
Middle Name:ALEXANDRA
Last Name:TEMPORAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KAYLIE
Other - Middle Name:ALEXANDRA
Other - Last Name:ELDORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:824 SOUTHPARK CIR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75752-6943
Mailing Address - Country:US
Mailing Address - Phone:903-675-7376
Mailing Address - Fax:903-677-4234
Practice Address - Street 1:824 SOUTHPARK CIR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75752-6943
Practice Address - Country:US
Practice Address - Phone:903-675-7376
Practice Address - Fax:903-677-4234
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA09471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant