Provider Demographics
NPI:1346778685
Name:URBANEK, KYLE PATRICK
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:PATRICK
Last Name:URBANEK
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:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:705 E MARSHALL AVE STE 5000
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5660
Practice Address - Country:US
Practice Address - Phone:903-316-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134194363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP02270110OtherMEDICARE RAIL ROAD
TX817780OtherMEDICARE
TX8LE707OtherBCBS
TX380278704Medicaid