Healthcare Provider Details

I. General information

NPI: 1205766243
Provider Name (Legal Business Name): PRESTON BUCKLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 SHOUP AVE W
TWIN FALLS ID
83301-4550
US

IV. Provider business mailing address

1576 VALENCIA ST
TWIN FALLS ID
83301-5657
US

V. Phone/Fax

Practice location:
  • Phone: 208-410-3578
  • Fax:
Mailing address:
  • Phone: 208-431-8337
  • Fax: 208-431-8337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberVR109587E
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: