Provider Demographics
NPI:1598036865
Name:BUCKLEY, JACOB D (CRNA)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:D
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 52404
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-2404
Mailing Address - Country:US
Mailing Address - Phone:256-429-5071
Mailing Address - Fax:256-429-4674
Practice Address - Street 1:1 HOSPITAL DR SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6455
Practice Address - Country:US
Practice Address - Phone:256-429-5074
Practice Address - Fax:256-429-4674
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9257640367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9257640OtherFL LICENSE
AL1-136658OtherALABAMA CRNA LICENSE