Healthcare Provider Details

I. General information

NPI: 1174173066
Provider Name (Legal Business Name): TIMOTHY AUSTIN BUXMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2019
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S NEW BALLAS RD
SAINT LOUIS MO
63141-8221
US

IV. Provider business mailing address

11490 DOUBLE T LN
BRIDGETON MO
63044-2901
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-9912
  • Fax:
Mailing address:
  • Phone: 314-973-6008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number0
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number2016014841
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: