Provider Demographics
NPI:1760956387
Name:CRAVER, KYLE LYNN
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:LYNN
Last Name:CRAVER
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 1:10269 S WHEEL SPOKE LN
Mailing Address - Street 2:
Mailing Address - City:VAIL
Mailing Address - State:AZ
Mailing Address - Zip Code:85641-3515
Mailing Address - Country:US
Mailing Address - Phone:336-239-1464
Mailing Address - Fax:
Practice Address - Street 1:10120 E OLD VAIL RD STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85747-9414
Practice Address - Country:US
Practice Address - Phone:520-989-8012
Practice Address - Fax:520-989-8014
Is Sole Proprietor?:No
Enumeration Date:2019-01-16
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7529171000000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No171000000XOther Service ProvidersMilitary Health Care Provider