Healthcare Provider Details

I. General information

NPI: 1376308908
Provider Name (Legal Business Name): KYLE HIETPAS PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2024
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3129 VICENTE ST
SAN FRANCISCO CA
94116-2740
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 415-661-1057
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number16648-024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL27686
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP029386T
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-6008
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberCP034963T
License Number StateAZ
# 6
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number307572
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: