Healthcare Provider Details

I. General information

NPI: 1871841569
Provider Name (Legal Business Name): JEANETTE MARIE BUCZACKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2012
Last Update Date: 07/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

855 SPRINGDALE DR STE 120
EXTON PA
19341-2836
US

IV. Provider business mailing address

3457 WEST CHESTER PIKE SUITE 120
NEWTOWN SQUARE PA
19073
US

V. Phone/Fax

Practice location:
  • Phone: 610-561-6100
  • Fax: 610-524-0133
Mailing address:
  • Phone: 610-353-6600
  • Fax: 610-353-3399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA004088
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: