Healthcare Provider Details

I. General information

NPI: 1538719521
Provider Name (Legal Business Name): KYLE WATRY PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 09/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 15TH ST STE 36A
SAN FRANCISCO CA
94103-5032
US

IV. Provider business mailing address

550 15TH ST STE 36A
SAN FRANCISCO CA
94103-5032
US

V. Phone/Fax

Practice location:
  • Phone: 415-701-1000
  • Fax: 888-246-1403
Mailing address:
  • Phone: 415-701-1000
  • Fax: 888-246-1403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number295445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: