Basic Information
| Provider Information | |||||||||
| NPI: | 1992979785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COFFMAN | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | WAYNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 290 NE TUDOR RD | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640865696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165245522 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 290 NE TUDOR RD | ||||||||
| Address2: | |||||||||
| City: | LEES SUMMIT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640865696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8165245522 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2008 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 37682 | IA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 208M00000X | 2008021055 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 53318 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200601800B | 05 | KS | MEDICAID |