Provider Demographics
NPI:1891511432
Name:SUE, KYSEN DANE (CPT)
Entity type:Individual
Prefix:
First Name:KYSEN
Middle Name:DANE
Last Name:SUE
Suffix:
Gender:M
Credentials:CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5815 82ND ST, SUITE 145 / PMB 108
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424
Mailing Address - Country:US
Mailing Address - Phone:806-599-6299
Mailing Address - Fax:
Practice Address - Street 1:4617 50TH ST STE 5
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-3507
Practice Address - Country:US
Practice Address - Phone:806-599-6299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXNPCN-17321-11162246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy