Healthcare Provider Details

I. General information

NPI: 1598933491
Provider Name (Legal Business Name): KYLE NOSKOVIAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 05/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E PRIMROSE ST STE 550
SPRINGFIELD MO
65807-5180
US

IV. Provider business mailing address

4743 E SUGARMAPLE DR
SPRINGFIELD MO
65809-2439
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-4647
  • Fax:
Mailing address:
  • Phone: 619-850-6450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2009023903
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: