Provider Demographics
NPI:1144508904
Name:FARR, KYLE M (NP-C)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:M
Last Name:FARR
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1856 TRADITION DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-5808
Mailing Address - Country:US
Mailing Address - Phone:269-352-8031
Mailing Address - Fax:734-259-2805
Practice Address - Street 1:640 STARKWEATHER ST STE C
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1371
Practice Address - Country:US
Practice Address - Phone:734-259-2804
Practice Address - Fax:734-259-2805
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704253005363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12304421OtherCAQH