Provider Demographics
NPI:1528033073
Name:WAHLSTROM, KYLE L (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:L
Last Name:WAHLSTROM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 SMITH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102-2383
Mailing Address - Country:US
Mailing Address - Phone:952-843-4333
Mailing Address - Fax:952-843-4301
Practice Address - Street 1:310 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2393
Practice Address - Country:US
Practice Address - Phone:952-843-4333
Practice Address - Fax:952-843-4301
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN39709174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH18643Medicare UPIN