Provider Demographics
NPI:1831670074
Name:TANNER, KYLE ERWIN (DPT)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ERWIN
Last Name:TANNER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5119 WATERFORD CT
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-7317
Mailing Address - Country:US
Mailing Address - Phone:254-592-8982
Mailing Address - Fax:
Practice Address - Street 1:1802 S 31ST ST
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504-6712
Practice Address - Country:US
Practice Address - Phone:254-778-4231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1301545225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist