Provider Demographics
NPI:1346908464
Name:BUCKWAY, JACOB (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BUCKWAY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1059 N 175 E
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-2477
Mailing Address - Country:US
Mailing Address - Phone:801-719-0045
Mailing Address - Fax:
Practice Address - Street 1:5475 S 500 E
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-6905
Practice Address - Country:US
Practice Address - Phone:801-479-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT94443013102367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered