Healthcare Provider Details

I. General information

NPI: 1164441333
Provider Name (Legal Business Name): PROFFER SURGICAL ASSOCIATES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 WALLACE BLVD
AMARILLO TX
79106-1799
US

IV. Provider business mailing address

1611 WALLACE BLVD
AMARILLO TX
79106-1799
US

V. Phone/Fax

Practice location:
  • Phone: 806-354-4900
  • Fax: 806-352-4987
Mailing address:
  • Phone: 806-354-4900
  • Fax: 806-352-4987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberK6910
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberK3932
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberM0532
License Number StateTX

VIII. Authorized Official

Name: LIANA PROFFER
Title or Position: PHYSICIAN
Credential:
Phone: 806-354-4900