1477949394 NPI number — KYLE MATTHEW JUDKINS DO

Table of content: KYLE MATTHEW JUDKINS DO (NPI 1477949394)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477949394 NPI number — KYLE MATTHEW JUDKINS DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUDKINS
Provider First Name:
KYLE
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477949394
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 TATE BLVD SE STE 190
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HICKORY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28602-4042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-294-7793
Provider Business Mailing Address Fax Number:
828-330-2060

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
159 WEAVER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEAVERVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28787-8345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-258-8800
Provider Business Practice Location Address Fax Number:
828-258-0416
Provider Enumeration Date:
04/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2017-01214 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QS0010X , with the licence number: 2017-01214 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NN8581A . This is a "MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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