Healthcare Provider Details

I. General information

NPI: 1275828915
Provider Name (Legal Business Name): THERESA G BUKS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2011
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 HARRISON AVE, LL100 MOAKLEY
BOSTON MA
02118-2905
US

IV. Provider business mailing address

960 MASSACHUSETTS AVE FL 2
BOSTON MA
02118-2690
US

V. Phone/Fax

Practice location:
  • Phone: 617-638-7070
  • Fax: 617-638-7037
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA4186
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: