Provider Demographics
NPI:1689547549
Name:MADEIRA, KYLER
Entity type:Individual
Prefix:
First Name:KYLER
Middle Name:
Last Name:MADEIRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N SYCAMORE AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7552
Mailing Address - Country:US
Mailing Address - Phone:813-361-2185
Mailing Address - Fax:
Practice Address - Street 1:1320 N SYCAMORE AVE APT 304
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-7552
Practice Address - Country:US
Practice Address - Phone:813-361-2185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-26
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95036804363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty