1194796839 NPI number — MR. PAUL ROBERT BUCHANAN PA-C

Table of content: MR. PAUL ROBERT BUCHANAN PA-C (NPI 1194796839)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194796839 NPI number — MR. PAUL ROBERT BUCHANAN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCHANAN
Provider First Name:
PAUL
Provider Middle Name:
ROBERT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194796839
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1608 TOWN CENTER CIR STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33326-3639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-349-2345
Provider Business Mailing Address Fax Number:
954-641-1080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 TOWN CENTER CIR
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
WESTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-389-5900
Provider Business Practice Location Address Fax Number:
954-389-5751
Provider Enumeration Date:
01/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA9102522 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X , with the licence number: PA9102522 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9102522 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002876700 . This is a "GROUP MEDICAID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: K0493 . This is a "GROUP MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 002603000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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