Provider Demographics
NPI:1427614262
Name:FAULKNER, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FAULKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4165 QUARLES CT
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:VA
Mailing Address - Zip Code:22801-3576
Mailing Address - Country:US
Mailing Address - Phone:540-434-1664
Mailing Address - Fax:540-433-5931
Practice Address - Street 1:10375 PARK MEADOWS DR # 270
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-6735
Practice Address - Country:US
Practice Address - Phone:303-351-5995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-16
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant