Provider Demographics
NPI:1033616909
Name:WAISANEN, KYLE MATTHEW (MD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MATTHEW
Last Name:WAISANEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:923 SPRING ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2800
Mailing Address - Country:US
Mailing Address - Phone:239-763-0345
Mailing Address - Fax:
Practice Address - Street 1:923 SPRING ST STE 101
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2800
Practice Address - Country:US
Practice Address - Phone:239-763-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301513351208800000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118384100Medicaid
MI4301513351OtherMI LICENSE