Healthcare Provider Details

I. General information

NPI: 1730559790
Provider Name (Legal Business Name): SEAN BUCKLEY FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2015
Last Update Date: 09/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

923 W 3RD ST
PEMBROKE NC
28372
US

IV. Provider business mailing address

2600 N ELM ST
LUMBERTON NC
28358-3011
US

V. Phone/Fax

Practice location:
  • Phone: 910-521-0564
  • Fax: 910-521-8091
Mailing address:
  • Phone: 910-671-5367
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP8198
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number282918
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: