Basic Information
| Provider Information | |||||||||
| NPI: | 1366932311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIHAYLO | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1706 S MERIDIAN | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538488797 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1706 S MERIDIAN | ||||||||
| Address2: | |||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983717516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2538488797 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 07/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | MD61296869 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 208000000X | MD61296869 | WA | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080S0010X | MD61296869 | WA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Sports Medicine |
No ID Information.