Provider Demographics
NPI:1366862526
Name:FJERSTAD, KYLE (PAC)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:FJERSTAD
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5418 W LONE STAR DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-6733
Mailing Address - Country:US
Mailing Address - Phone:520-403-5067
Mailing Address - Fax:
Practice Address - Street 1:101 CIVIC CENTER LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5607
Practice Address - Country:US
Practice Address - Phone:928-885-8185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant