Healthcare Provider Details

I. General information

NPI: 1760859995
Provider Name (Legal Business Name): CONNIE BUCK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2015
Last Update Date: 10/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SW COAST HWY STE 203
NEWPORT OR
97365-5215
US

IV. Provider business mailing address

2620 E BARNETT RD STE H
MEDFORD OR
97504-8383
US

V. Phone/Fax

Practice location:
  • Phone: 541-265-4947
  • Fax: 541-574-7670
Mailing address:
  • Phone: 541-789-8176
  • Fax: 541-778-9614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number15987-1395
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number99694
License Number StateMT
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201901366NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: