Provider Demographics
NPI:1164178992
Name:GOODBAN, KYLE ROBERT
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ROBERT
Last Name:GOODBAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10150 N 150TH ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:NE
Mailing Address - Zip Code:68462-1595
Mailing Address - Country:US
Mailing Address - Phone:402-405-2145
Mailing Address - Fax:
Practice Address - Street 1:5000 SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68504-2760
Practice Address - Country:US
Practice Address - Phone:402-465-7508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program