Provider Demographics
NPI:1063921955
Name:HILLIS, KYLE MATTHEW (CAA)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:MATTHEW
Last Name:HILLIS
Suffix:
Gender:M
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 ATLANTIC BLVD UNIT 234
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2434
Mailing Address - Country:US
Mailing Address - Phone:912-856-1098
Mailing Address - Fax:
Practice Address - Street 1:820 PRUDENTIAL DR STE 606
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8208
Practice Address - Country:US
Practice Address - Phone:904-398-3356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-24
Last Update Date:2017-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant