Provider Demographics
NPI:1962452458
Name:TRAIL, KYNAN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:KYNAN
Middle Name:CHARLES
Last Name:TRAIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 FOX RUN PKWY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-5370
Mailing Address - Country:US
Mailing Address - Phone:605-668-9670
Mailing Address - Fax:605-668-0371
Practice Address - Street 1:2525 FOX RUN PKWY
Practice Address - Street 2:SUITE 204
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-5370
Practice Address - Country:US
Practice Address - Phone:605-668-9670
Practice Address - Fax:605-668-0371
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4733208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE46045455602Medicaid
SD7301750Medicaid
NE46045455602Medicaid
SDH20124Medicare UPIN
NE273809TRMedicare ID - Type Unspecified