Provider Demographics
NPI:1508140682
Name:TASE, KYLE JOHN
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JOHN
Last Name:TASE
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:PO BOX 6005
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-6005
Mailing Address - Country:US
Mailing Address - Phone:307-789-3710
Mailing Address - Fax:307-789-0823
Practice Address - Street 1:50 ALLEGIANCE CIR
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-3804
Practice Address - Country:US
Practice Address - Phone:307-789-3710
Practice Address - Fax:307-789-0823
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator