Provider Demographics
NPI:1104313519
Name:MANSCUK, KYLE RICHARD (PA)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:RICHARD
Last Name:MANSCUK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:
Practice Address - Street 1:4945 SW 49TH PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-9673
Practice Address - Country:US
Practice Address - Phone:352-237-9430
Practice Address - Fax:352-237-9698
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9114325363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical