Provider Demographics
NPI:1629455647
Name:KREITZMANN, KYLE PAUL
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:PAUL
Last Name:KREITZMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 BECK AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3920
Mailing Address - Country:US
Mailing Address - Phone:307-250-3085
Mailing Address - Fax:307-586-2376
Practice Address - Street 1:1507 BECK AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-3920
Practice Address - Country:US
Practice Address - Phone:307-250-3085
Practice Address - Fax:307-586-2376
Is Sole Proprietor?:No
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY133205801Medicaid