Provider Demographics
NPI:1639664535
Name:PROFFITT, JOHN KYLE (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:KYLE
Last Name:PROFFITT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SW ARCHER RD
Mailing Address - Street 2:BOX 100108
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0108
Mailing Address - Country:US
Mailing Address - Phone:352-273-5670
Mailing Address - Fax:
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-265-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363A00000X
FLPA9111400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100738100Medicaid