Provider Demographics
NPI:1952399206
Name:PROFFER, PATRICK JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JONATHAN
Last Name:PROFFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 WALLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1799
Mailing Address - Country:US
Mailing Address - Phone:806-352-1185
Mailing Address - Fax:806-352-4987
Practice Address - Street 1:1611 WALLACE BLVD
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1799
Practice Address - Country:US
Practice Address - Phone:806-352-1185
Practice Address - Fax:806-352-4987
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM05322086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174819602Medicaid
TXP00418009OtherPALMETTO GBS/RAILROAD MEDICARE
TXP00418009OtherPALMETTO GBS/RAILROAD MEDICARE