Provider Demographics
NPI:1720088073
Name:ADAMS, KYLE R (PT,DPT,CSCS,OCS, FAA)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:R
Last Name:ADAMS
Suffix:
Gender:M
Credentials:PT,DPT,CSCS,OCS, FAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 TAUGHANNOCK BLVD
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-252-3500
Mailing Address - Fax:607-252-3505
Practice Address - Street 1:310 TAUGHANNOCK BLVD
Practice Address - Street 2:SUITE 1C
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-252-3500
Practice Address - Fax:607-252-3505
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0230351225100000X
NY023035225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P43153Medicare UPIN
NYCC9470Medicare PIN