Provider Demographics
NPI:1568180784
Name:ANTONIO, KYLE (PTA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:ANTONIO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6895 RAMFOS CIR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-3216
Mailing Address - Country:US
Mailing Address - Phone:619-578-1483
Mailing Address - Fax:
Practice Address - Street 1:585 SATURN BLVD STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-4721
Practice Address - Country:US
Practice Address - Phone:619-591-1190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-15
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51482225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF2125959OtherDRIVER'S LICENSE