Provider Demographics
NPI:1194415836
Name:SCOTT, KYLE CALVIN
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:CALVIN
Last Name:SCOTT
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 1:707 S GOLDEN LEAF WAY
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-5507
Mailing Address - Country:US
Mailing Address - Phone:307-840-6489
Mailing Address - Fax:
Practice Address - Street 1:120 N 6TH ST E
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-4405
Practice Address - Country:US
Practice Address - Phone:307-856-9281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT141970411206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant