Provider Demographics
NPI:1396795621
Name:BULLMAN, JONATHAN FAIN (PA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:FAIN
Last Name:BULLMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5612 BALLEYBUNION DR
Mailing Address - Street 2:
Mailing Address - City:PACE
Mailing Address - State:FL
Mailing Address - Zip Code:32571-9585
Mailing Address - Country:US
Mailing Address - Phone:850-994-4245
Mailing Address - Fax:
Practice Address - Street 1:6002 BERRYHILL ROAD
Practice Address - Street 2:SANTA ROSA MEDICAL CENTER
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570
Practice Address - Country:US
Practice Address - Phone:850-626-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1061450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant