| Doctor Name: | KYLE HOLLENBACK |
| NPI Number: | 1932574381 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | 1330 |
| Business Practice Address: | 486 W 1st Ave Glenns Ferry, ID - 836232701 |
| Business Phone Number: | 2083667416 |
| Business Fax Number: | |
| Mailing Address: | 486 W 1st Ave, GLENNS FERRY |
| State: | ID |
| Postal Code: | 836232701 |
| Phone Number: | |
| Fax Number: | |
| NPI Enumeration Date: | 12/10/2015 |
| NPI Last Update Date: | 12/10/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 1330 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |