Provider Demographics
NPI:1184036105
Name:CHRISTOPHERSON, KYLE ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ROBERT
Last Name:CHRISTOPHERSON
Suffix:
Gender:M
Credentials:MD
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 4433
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-4433
Mailing Address - Country:US
Mailing Address - Phone:970-254-1686
Mailing Address - Fax:970-254-1687
Practice Address - Street 1:300 W OTTLEY AVE
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2118
Practice Address - Country:US
Practice Address - Phone:970-270-2259
Practice Address - Fax:970-858-0798
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-26
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO62042207LP2900X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184036105OtherNPI