Basic Information
| Provider Information | |||||||||
| NPI: | 1982170676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | CHRISTIAN | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1205 S GRANGE AVE STE 407 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053288900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1205 S GRANGE AVE STE 407 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571050410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6053288900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2018 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | CP001472 | SD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.