Basic Information
| Provider Information | |||||||||
| NPI: | 1003264292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCK | ||||||||
| FirstName: | DEVON | ||||||||
| MiddleName: | |||||||||
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| Credential: | APN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | FURTAK | ||||||||
| OtherFirstName: | DEVON | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 367 S. GULPH RD | ||||||||
| Address2: | ATT IPM CREDENTIALING | ||||||||
| City: | KING OF PRUSSIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194063121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6103824943 | ||||||||
| FaxNumber: | 6108783965 | ||||||||
| Practice Location | |||||||||
| Address1: | 316 MANATEE AVE W | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342058805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9417482277 | ||||||||
| FaxNumber: | 9417481958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2016 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 26NJ00661100 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2200X | 26NJ00661100 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2100X | ARNP9457878 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.