Provider Demographics
NPI:1609018092
Name:PROTHEROE, JOHN HUNTER (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HUNTER
Last Name:PROTHEROE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:303 NORTH CLYDE MORRIS BL
Mailing Address - Street 2:HALIFAX HEALTH MEDICAL CENTER
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-254-2285
Mailing Address - Fax:386-425-1304
Practice Address - Street 1:303 NORTH CLYDE MORRIS BL
Practice Address - Street 2:HALIFAX HEALTH MEDICAL CENTER
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-2285
Practice Address - Fax:386-425-1304
Is Sole Proprietor?:No
Enumeration Date:2009-03-31
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPA3742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000888400Medicaid
FLBR793ZMedicare PIN