Provider Demographics
NPI:1497493688
Name:IVERSON, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:IVERSON
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 1:2400 NW MYHRE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7672
Mailing Address - Country:US
Mailing Address - Phone:360-598-3764
Mailing Address - Fax:360-598-3282
Practice Address - Street 1:1880 POTTERY AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2518
Practice Address - Country:US
Practice Address - Phone:360-895-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61307247225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist