Healthcare Provider Details

I. General information

NPI: 1306093935
Provider Name (Legal Business Name): LISA ANN BUCKLEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HOBART ST
CADILLAC MI
49601-2331
US

IV. Provider business mailing address

PO BOX 58
CADILLAC MI
49601-0058
US

V. Phone/Fax

Practice location:
  • Phone: 231-876-7200
  • Fax:
Mailing address:
  • Phone: 866-898-7139
  • Fax: 616-975-9824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005320
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: