Healthcare Provider Details

I. General information

NPI: 1942993670
Provider Name (Legal Business Name): MR. JAMES RYLAND FLYTHE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 10/10/2023
Certification Date: 10/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4870 DEER LAKE DR E STE 4114
JACKSONVILLE FL
32246-6320
US

IV. Provider business mailing address

4870 DEER LAKE DR E STE 4114
JACKSONVILLE FL
32246-6320
US

V. Phone/Fax

Practice location:
  • Phone: 252-678-2127
  • Fax:
Mailing address:
  • Phone: 252-678-2127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9118025
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: