Provider Demographics
NPI:1376202770
Name:WILKIE, KYLE MASON (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MASON
Last Name:WILKIE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 MISSLER DR
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:TX
Mailing Address - Zip Code:76008-1813
Mailing Address - Country:US
Mailing Address - Phone:916-380-2993
Mailing Address - Fax:
Practice Address - Street 1:12550 SOUTH FWY STE 106
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-8438
Practice Address - Country:US
Practice Address - Phone:817-426-4401
Practice Address - Fax:817-426-4410
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32106225100000X
TX1362180225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist