Provider Demographics
NPI:1629223110
Name:YORGASON, KYLE R (DPM)
Entity Type:Individual
Prefix:DR
First Name:KYLE
Middle Name:R
Last Name:YORGASON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1075 N CURTIS RD STE 300
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-1348
Practice Address - Country:US
Practice Address - Phone:208-302-3100
Practice Address - Fax:208-302-3155
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-255213E00000X
PASC006038213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2593319OtherHIGHMARK BC BS
PA150016OtherGEISINGER
PA50105709OtherCAPITAL BLUE CROSS
PAP01022651OtherPALMETTO / RAILROAD MEDICARE
PA12933641OtherMULTIPLAN
PA1026781600003Medicaid
PAP01022651OtherPALMETTO / RAILROAD MEDICARE