Healthcare Provider Details

I. General information

NPI: 1871500165
Provider Name (Legal Business Name): JACQUELYN A BUCKLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELYN A DELISLE PA

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 ROUTE 9
GANSEVOORT NY
12831-1560
US

IV. Provider business mailing address

9 CAREY RD
QUEENSBURY NY
12804-7880
US

V. Phone/Fax

Practice location:
  • Phone: 518-761-6961
  • Fax: 518-761-1006
Mailing address:
  • Phone: 518-761-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010844
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: