Provider Demographics
NPI:1013663566
Name:WISNIEWSKI, KYLE WILLIAM (PTA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:WILLIAM
Last Name:WISNIEWSKI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11716 GREENWOOD AVE N APT 301
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8162
Mailing Address - Country:US
Mailing Address - Phone:206-349-3827
Mailing Address - Fax:
Practice Address - Street 1:1227 N 205TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-3214
Practice Address - Country:US
Practice Address - Phone:206-546-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61205687225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant