Provider Demographics
NPI:1356880660
Name:TEVEBAUGH, KYLE T
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:T
Last Name:TEVEBAUGH
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 1:1515 DELHI ST
Mailing Address - Street 2:STE 100
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52001-6389
Mailing Address - Country:US
Mailing Address - Phone:563-557-9111
Mailing Address - Fax:563-589-4046
Practice Address - Street 1:320 N GRANDVIEW AVE
Practice Address - Street 2:SUITE D
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52001-6328
Practice Address - Country:US
Practice Address - Phone:563-583-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant