Provider Demographics
NPI:1487066841
Name:BACKER, KYLE NATHAN (MD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:NATHAN
Last Name:BACKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:800-926-8273
Mailing Address - Fax:888-539-8781
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-636-8760
Practice Address - Fax:360-414-7599
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA155221207ZP0102X
WAMD61544789207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology