Provider Demographics
NPI:1164186813
Name:CHRISTIANSON, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:CHRISTIANSON
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 1:1401 8TH ST S # 3
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-3606
Mailing Address - Country:US
Mailing Address - Phone:701-261-7694
Mailing Address - Fax:
Practice Address - Street 1:1401 8TH ST S # 3
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-3606
Practice Address - Country:US
Practice Address - Phone:701-261-7694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8354175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist