Provider Demographics
NPI:1912340043
Name:SANNIEC, KYLE (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SANNIEC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9250 N 3RD ST STE 1003
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2402
Mailing Address - Country:US
Mailing Address - Phone:602-331-7811
Mailing Address - Fax:
Practice Address - Street 1:9250 N 3RD ST STE 1003
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2402
Practice Address - Country:US
Practice Address - Phone:602-331-7811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2020-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ609732086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program