Basic Information
| Provider Information | |||||||||
| NPI: | 1255008959 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UTNE | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | ANDREW | ||||||||
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| Credential: | MA, ATC, PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7211 PRESTON RD STE T1200 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750244700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693033000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7211 PRESTON RD STE T1200 | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750244700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4693033000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2021 | ||||||||
| LastUpdateDate: | 08/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT6749 | TX | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 225200000X | 2151789 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2151789 | 01 | TX | PHYSICAL THERAPIST ASSISTANT LICENSE NUMBER | OTHER | AT6749 | 01 | TX | ATHLETIC TRAINERS LICENSURE NUMBER | OTHER |