Healthcare Provider Details

I. General information

NPI: 1619892916
Provider Name (Legal Business Name): KYLE DAVID GOODMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2026
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 LANGHORNE NEWTOWN RD STE 120
LANGHORNE PA
19047-1211
US

IV. Provider business mailing address

47 E REVERE AVE
NORTHFIELD NJ
08225-2435
US

V. Phone/Fax

Practice location:
  • Phone: 267-364-9100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: