Provider Demographics
NPI:1497122881
Name:ST. PETER, KYLE ANDRE (AT, ATC, EMT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ANDRE
Last Name:ST. PETER
Suffix:
Gender:M
Credentials:AT, ATC, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41641 UTICA RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-3264
Mailing Address - Country:US
Mailing Address - Phone:586-747-7859
Mailing Address - Fax:
Practice Address - Street 1:41641 UTICA RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-3264
Practice Address - Country:US
Practice Address - Phone:586-747-7859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3203056420146N00000X
MI26010017182255A2300X
2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer