Provider Demographics
NPI:1407514698
Name:OSTAPUK, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:OSTAPUK
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 1:575 W PECOS RD APT 1094
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-7408
Mailing Address - Country:US
Mailing Address - Phone:602-432-8836
Mailing Address - Fax:
Practice Address - Street 1:575 W PECOS RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-7402
Practice Address - Country:US
Practice Address - Phone:602-432-8836
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-04
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-17817225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist