Healthcare Provider Details

I. General information

NPI: 1639664535
Provider Name (Legal Business Name): JOHN KYLE PROFFITT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

1600 SW ARCHER RD BOX 100108
GAINESVILLE FL
32610-0108
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0111
  • Fax:
Mailing address:
  • Phone: 352-273-5670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111400
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: