Provider Demographics
NPI:1336507847
Name:TIPTON, KYLE (CRNA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:TIPTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4741 EAGLERIDGE CIR APT 206
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-2272
Mailing Address - Country:US
Mailing Address - Phone:870-917-5734
Mailing Address - Fax:
Practice Address - Street 1:4741 EAGLERIDGE CIRCLE
Practice Address - Street 2:206
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:870-917-5734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-29
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO111291367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered