Healthcare Provider Details

I. General information

NPI: 1033616909
Provider Name (Legal Business Name): KYLE MATTHEW WAISANEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 HARBOR BLVD STE 8
PORT CHARLOTTE FL
33952-5038
US

IV. Provider business mailing address

2400 HARBOR BLVD STE 8
PORT CHARLOTTE FL
33952-5038
US

V. Phone/Fax

Practice location:
  • Phone: 941-766-5070
  • Fax: 941-766-5071
Mailing address:
  • Phone: 941-766-5070
  • Fax: 941-766-5071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME162353
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number4301513351
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: