Healthcare Provider Details

I. General information

NPI: 1124693759
Provider Name (Legal Business Name): BARAKA JEANCY TCHATENDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JEANCY TCHATENDA BARAKA

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-2178
US

IV. Provider business mailing address

PO BOX 100286
GAINESVILLE FL
32610-0286
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0761
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114822
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: