Healthcare Provider Details

I. General information

NPI: 1336277441
Provider Name (Legal Business Name): MARK BURACZYNSKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 CHANTICLEER AVE
SANTA CRUZ CA
95065-1816
US

IV. Provider business mailing address

2025 SOQUEL AVE
SANTA CRUZ CA
95062-1323
US

V. Phone/Fax

Practice location:
  • Phone: 831-477-2200
  • Fax:
Mailing address:
  • Phone: 831-479-6603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13445
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: