Provider Demographics
NPI:1083667851
Name:GOLENO, KYLE JOSEPH (PA-C)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:JOSEPH
Last Name:GOLENO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2290 SACRAMENTO ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2929
Mailing Address - Country:US
Mailing Address - Phone:707-643-5785
Mailing Address - Fax:707-643-8810
Practice Address - Street 1:2290 SACRAMENTO ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2929
Practice Address - Country:US
Practice Address - Phone:707-643-5785
Practice Address - Fax:707-643-8810
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
CAPA16376363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ97788ZOtherMEDICARE PTAN
CAZZZ97788ZOtherMEDICARE PTAN
CAP87671Medicare UPIN