Healthcare Provider Details

I. General information

NPI: 1225559859
Provider Name (Legal Business Name): VERONICA JAE BUCHANAN ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 07/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 S BRENTWOOD BLVD
RICHMOND HEIGHTS MO
63117-1223
US

IV. Provider business mailing address

1263 WOODLAND TRAILS DR
KIRKWOOD MO
63122-6726
US

V. Phone/Fax

Practice location:
  • Phone: 314-644-1978
  • Fax:
Mailing address:
  • Phone: 417-599-1518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2015040786
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: