Provider Demographics
NPI:1619617289
Name:LARSON, KYLE MICHAEL (IDMT)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:MICHAEL
Last Name:LARSON
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:655 7TH ST BLDG 700
Mailing Address - Street 2:
Mailing Address - City:ROBINS AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31098-2227
Mailing Address - Country:US
Mailing Address - Phone:478-327-7850
Mailing Address - Fax:
Practice Address - Street 1:655 7TH ST BLDG 700
Practice Address - Street 2:
Practice Address - City:ROBINS AFB
Practice Address - State:GA
Practice Address - Zip Code:31098-2227
Practice Address - Country:US
Practice Address - Phone:478-327-7850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians