Provider Demographics
NPI:1386035731
Name:TIERNEY, KYLE (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:TIERNEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 TAMA ST SE STE 700
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52403-4558
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4700 TAMA ST SE STE 700
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-4558
Practice Address - Country:US
Practice Address - Phone:319-447-0700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA076477225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB1213042Medicare PIN
IAIB1212040Medicare PIN
IAIB1213Medicare PIN
IAIB1212Medicare PIN