Provider Demographics
NPI:1942638325
Name:GOHAM, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:GOHAM
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:W180N8085 TOWN HALL RD
Mailing Address - Street 2:DEPT OF ANESTHESIOLOGY
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3518
Mailing Address - Country:US
Mailing Address - Phone:262-257-5100
Mailing Address - Fax:
Practice Address - Street 1:W180N8085 TOWN HALL RD
Practice Address - Street 2:DEPT OF ANESTHESIOLOGY
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3518
Practice Address - Country:US
Practice Address - Phone:262-257-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-23
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006981367H00000X
WI7717367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant