Healthcare Provider Details

I. General information

NPI: 1598707853
Provider Name (Legal Business Name): WILLIAM SHANE KYLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10561 JEFFREYS ST SUITE 100
HENDERSON NV
89052-4266
US

IV. Provider business mailing address

PO BOX 629
ALTOONA IA
50009-0629
US

V. Phone/Fax

Practice location:
  • Phone: 702-478-5620
  • Fax: 702-478-5093
Mailing address:
  • Phone: 515-645-9911
  • Fax: 515-967-5581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10972
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: