Provider Demographics
NPI:1538123492
Name:SWANSON, KYLE EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:EDWARD
Last Name:SWANSON
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 1:1111 EMERALD BAY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6207
Mailing Address - Country:US
Mailing Address - Phone:530-543-5659
Mailing Address - Fax:530-541-8723
Practice Address - Street 1:935 MICA DR STE 13
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89705-7181
Practice Address - Country:US
Practice Address - Phone:775-783-3065
Practice Address - Fax:775-267-1829
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2015-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12366207XX0005X
CAA73421207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I67691Medicare UPIN
NVV104932Medicare PIN
CAAP304YMedicare PIN