Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 25450 | MN |
NPI | 1003811464 |
---|---|
Provider Name | David Stuart Kyllo |
First Address | Eagan, MN 55122-4301 |
Second Address | Eagan, MN 55122-4301 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A95834 | (02) | MN |