Healthcare Provider Details

I. General information

NPI: 1093109803
Provider Name (Legal Business Name): LAUREN DUANE BUCKINGHAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1449 W IRVING PARK RD
CHICAGO IL
60613-1922
US

IV. Provider business mailing address

3740 N HALSTED ST APT 1224
CHICAGO IL
60613-5611
US

V. Phone/Fax

Practice location:
  • Phone: 872-315-3375
  • Fax:
Mailing address:
  • Phone: 872-315-3375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.005383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: