Provider Demographics
NPI:1326588930
Name:BUCHANNON, MALCOLM WENDELL (LPTA)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:WENDELL
Last Name:BUCHANNON
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11565 HARTS RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-3777
Mailing Address - Country:US
Mailing Address - Phone:352-215-9878
Mailing Address - Fax:
Practice Address - Street 1:11565 HARTS RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-3777
Practice Address - Country:US
Practice Address - Phone:904-751-1834
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL27323225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant