Provider Demographics
NPI:1396000816
Name:KIRBY, KYLE ADAM
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ADAM
Last Name:KIRBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 E JACKSON RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-7403
Mailing Address - Country:US
Mailing Address - Phone:317-385-2375
Mailing Address - Fax:
Practice Address - Street 1:875 E JACKSON RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45502-7403
Practice Address - Country:US
Practice Address - Phone:317-385-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH13476367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered