Healthcare Provider Details

I. General information

NPI: 1952399206
Provider Name (Legal Business Name): PATRICK JONATHAN PROFFER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 02/20/2014
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: 806-352-1185
  • Fax: 806-352-4987
Mailing address:
  • Phone: 806-352-1185
  • Fax: 806-352-4987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberM0532
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: