Healthcare Provider Details

I. General information

NPI: 1164016663
Provider Name (Legal Business Name): JASON BUCKALOO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13800 VETERANS WAY
ORLANDO FL
32827-7401
US

IV. Provider business mailing address

13800 VETERANS WAY
ORLANDO FL
32827-7401
US

V. Phone/Fax

Practice location:
  • Phone: 407-631-0100
  • Fax:
Mailing address:
  • Phone: 76-310-1004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9117647
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAT9117647
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: