Healthcare Provider Details

I. General information

NPI: 1104313519
Provider Name (Legal Business Name): KYLE RICHARD MANSCUK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2018
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4945 SW 49TH PL
OCALA FL
34474-9673
US

IV. Provider business mailing address

4371 VERONICA S SHOEMAKER BLVD
FORT MYERS FL
33916-2216
US

V. Phone/Fax

Practice location:
  • Phone: 352-237-9430
  • Fax: 352-237-9698
Mailing address:
  • Phone: 239-274-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9114325
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: