Provider Demographics
NPI:1265533434
Name:SHADLE, KYLE M (CRNA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:M
Last Name:SHADLE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1708 COIT RD
Mailing Address - Street 2:SUITE 220A
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-5024
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1708 COIT RD
Practice Address - Street 2:SUITE 220A
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-5024
Practice Address - Country:US
Practice Address - Phone:972-596-6400
Practice Address - Fax:972-867-4766
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX710328367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9186616OtherFL CRNA LICENSE
FLG3766OtherBCBS OF FL #
FLG3766OtherBCBS OF FL #