Provider Demographics
NPI:1699257576
Name:LARUE, KYLEN (PA-C)
Entity type:Individual
Prefix:
First Name:KYLEN
Middle Name:
Last Name:LARUE
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 1:139 BASIN HILL RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANNON
Mailing Address - State:PA
Mailing Address - Zip Code:17020-9649
Mailing Address - Country:US
Mailing Address - Phone:717-756-6713
Mailing Address - Fax:
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-808-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical