Provider Demographics
NPI:1538564174
Name:RICKSTAD, KYLE MATTHEW (PA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:MATTHEW
Last Name:RICKSTAD
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:130 NORTH ST
Mailing Address - Street 2:CAPE COD ORTHOPAEDICS AND SPORTS MEDICINE, P.C.
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-3825
Mailing Address - Country:US
Mailing Address - Phone:508-568-3761
Mailing Address - Fax:508-775-2352
Practice Address - Street 1:130 NORTH ST
Practice Address - Street 2:CAPE COD ORTHOPAEDICS AND SPORTS MEDICINE, P.C.
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3825
Practice Address - Country:US
Practice Address - Phone:508-568-3761
Practice Address - Fax:508-775-2352
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2016-10-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MAPA5210363AS0400X
VT055.0031264363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical