Provider Demographics
NPI:1174878185
Name:RASMUS, KYLE D (PTA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:D
Last Name:RASMUS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 N WESTFIELD ST
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54902-3217
Mailing Address - Country:US
Mailing Address - Phone:920-232-0128
Mailing Address - Fax:920-232-0193
Practice Address - Street 1:1130 N WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-3217
Practice Address - Country:US
Practice Address - Phone:920-232-0128
Practice Address - Fax:920-232-0193
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1080 19174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist