Healthcare Provider Details

I. General information

NPI: 1912158056
Provider Name (Legal Business Name): KYLE TRAUTSCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2008
Last Update Date: 11/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2815 LAKESHORE DR APT 1
LA CROSSE WI
54603-6006
US

IV. Provider business mailing address

2815 LAKESHORE DR APT 1
LA CROSSE WI
54603-6006
US

V. Phone/Fax

Practice location:
  • Phone: 608-797-3008
  • Fax:
Mailing address:
  • Phone: 608-797-3008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number4596-027
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number201458
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: