Provider Demographics
NPI:1649623968
Name:SMITH, KYLE BRYANT (BS)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:BRYANT
Last Name:SMITH
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 9TH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4408
Mailing Address - Country:US
Mailing Address - Phone:616-881-3421
Mailing Address - Fax:
Practice Address - Street 1:825 9TH AVE APT 2
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4408
Practice Address - Country:US
Practice Address - Phone:616-881-3421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic