Provider Demographics
NPI:1073950598
Name:SHAFFER, KYLE (PT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5285
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68802-5285
Mailing Address - Country:US
Mailing Address - Phone:308-382-0344
Mailing Address - Fax:308-382-3241
Practice Address - Street 1:3601 CIMARRON PLZ STE 100
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:NE
Practice Address - Zip Code:68901-2883
Practice Address - Country:US
Practice Address - Phone:402-463-2085
Practice Address - Fax:402-463-2062
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE3206225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist