Healthcare Provider Details

I. General information

NPI: 1316449515
Provider Name (Legal Business Name): JACOB THOMAS BUKAWESKI AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2018
Last Update Date: 05/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610
US

IV. Provider business mailing address

PO BOX 100108
GAINESVILLE FL
32610-0108
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5667
  • Fax:
Mailing address:
  • Phone: 352-273-5667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN9385496
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9385496
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: