Healthcare Provider Details

I. General information

NPI: 1750542452
Provider Name (Legal Business Name): KYLAN D PETERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 01/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 N COLLEGE RD SUITE B
TWIN FALLS ID
83301-3382
US

IV. Provider business mailing address

PO BOX 587
TWIN FALLS ID
83303-0587
US

V. Phone/Fax

Practice location:
  • Phone: 208-814-7350
  • Fax: 208-732-8508
Mailing address:
  • Phone: 208-814-7400
  • Fax: 208-814-7491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberO0713
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: