=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871841569
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEANETTE MARIE BUCZACKI PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2012
-----------------------------------------------------
Last Update Date | 07/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 855 SPRINGDALE DR STE 120
-----------------------------------------------------
City | EXTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19341-2836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-561-6100
-----------------------------------------------------
Fax | 610-524-0133
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3457 WEST CHESTER PIKE SUITE 120
-----------------------------------------------------
City | NEWTOWN SQUARE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-353-6600
-----------------------------------------------------
Fax | 610-353-3399
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | OA004088
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------