Provider Demographics
NPI:1639460397
Name:IVERSON, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:IVERSON
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:RAF LAKENHEATH 48MDG/SGHC
Mailing Address - Street 2:UNIT 5115
Mailing Address - City:APO
Mailing Address - State:MS
Mailing Address - Zip Code:39534-2508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:RAF LAKENHEATH 48MDG/SGHC
Practice Address - Street 2:UNIT 5115
Practice Address - City:APO
Practice Address - State:MS
Practice Address - Zip Code:39534-2508
Practice Address - Country:US
Practice Address - Phone:864-608-1795
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS28433208600000X
VA0101256367208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty