Healthcare Provider Details

I. General information

NPI: 1467538462
Provider Name (Legal Business Name): KRYSTAL M BUCKLAND PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 12/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N 35TH AVE STE 345
HOLLYWOOD FL
33021
US

IV. Provider business mailing address

2900 CORPORATE WAY DOOR D
MIRAMAR FL
33025-3925
US

V. Phone/Fax

Practice location:
  • Phone: 954-986-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 9103945
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: