Provider Demographics
NPI:1003032434
Name:CLYDE, KYLE EUGENE (LMP)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:EUGENE
Last Name:CLYDE
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2809 MERIDIAN E.
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98371
Mailing Address - Country:US
Mailing Address - Phone:253-840-1100
Mailing Address - Fax:253-840-1199
Practice Address - Street 1:2809 MERIDIAN E.
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98371
Practice Address - Country:US
Practice Address - Phone:253-840-1100
Practice Address - Fax:253-840-1199
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015312174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist