MEDICARE: MR. KYLE MATTHEW HILLIS CAA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367H00000X	Anesthesiologist Assistant		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063921955
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KYLE MATTHEW HILLIS CAA

Provider Business Mailing Address
First Line	:	5201 ATLANTIC BLVD UNIT 234
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-2434
Country	:	US
Telephone Number	:	912-856-1098
Fax Number	:

Provider Business Practice Location Address
First Line	:	820 PRUDENTIAL DR STE 606
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8208
Country	:	US
Telephone Number	:	904-398-3356
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2017
Last Update Date	:	09/24/2017

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