Provider Demographics
NPI:1578388633
Name:DEISIG, KYLE (FNP-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:DEISIG
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 LAGUNA RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE NEST
Mailing Address - State:NM
Mailing Address - Zip Code:87718-9003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 133
Practice Address - Street 2:
Practice Address - City:ANGEL FIRE
Practice Address - State:NM
Practice Address - Zip Code:87710-0133
Practice Address - Country:US
Practice Address - Phone:575-377-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-22
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM66201363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care