Provider Demographics
NPI:1871718544
Name:WILSON, KYLE STEVEN (MED, ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:STEVEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MED, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8161 TONE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-0214
Mailing Address - Country:US
Mailing Address - Phone:702-895-4037
Mailing Address - Fax:702-895-4474
Practice Address - Street 1:4505 S MARYLAND PKWY
Practice Address - Street 2:BOX 450007
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89154-9900
Practice Address - Country:US
Practice Address - Phone:702-895-4037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05060022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer