Provider Demographics
NPI:1467538462
Name:BUCKLAND, KRYSTAL M (PA-C)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:M
Last Name:BUCKLAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1150 N 35TH AVE
Practice Address - Street 2:STE 345
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021
Practice Address - Country:US
Practice Address - Phone:954-986-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103945363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAA241VOtherMEDICARE PTAN
FL2928337-00Medicaid