Healthcare Provider Details

I. General information

NPI: 1053763664
Provider Name (Legal Business Name): KYLE SWANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 E 1ST ST SUITE 310
DIXON IL
61021-3166
US

IV. Provider business mailing address

215 E 1ST ST SUITE 310
DIXON IL
61021-3166
US

V. Phone/Fax

Practice location:
  • Phone: 515-210-9777
  • Fax: 815-285-5699
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016.005777
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016005777
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: