Healthcare Provider Details

I. General information

NPI: 1285414730
Provider Name (Legal Business Name): MELISSA BUCKLIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 EAST ADAMS STREET
SYRACUSE NY
13210
US

IV. Provider business mailing address

251 SALINA MEADOWS PARKWAY STE 100
SYRACUSE NY
13212
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-8200
  • Fax: 315-464-8206
Mailing address:
  • Phone: 315-464-2096
  • Fax: 315-464-2010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA200002041
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number035913
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110009633
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number035913
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: