Healthcare Provider Details

I. General information

NPI: 1225724511
Provider Name (Legal Business Name): KYLE MATHEW PARKER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 QUEENSBROOKE BLVD STE 100
SAINT PETERS MO
63376-7881
US

IV. Provider business mailing address

2046 QUEENSBROOKE BLVD STE 100
SAINT PETERS MO
63376-7881
US

V. Phone/Fax

Practice location:
  • Phone: 505-265-1711
  • Fax:
Mailing address:
  • Phone: 618-225-0996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberIA-0008413129
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: