Provider Demographics
NPI:1053763664
Name:SWANSON, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:SWANSON
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 1:215 E 1ST ST
Mailing Address - Street 2:SUITE 310
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3166
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 E 1ST ST
Practice Address - Street 2:SUITE 310
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-3166
Practice Address - Country:US
Practice Address - Phone:515-210-9777
Practice Address - Fax:815-285-5699
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016005777213ES0131X
IL016.005777213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL135000913OtherPROFESSIONAL LICENSE