Healthcare Provider Details

I. General information

NPI: 1730173139
Provider Name (Legal Business Name): ELIZABETH D BUCKLEY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOPPIN ST 3RD FLOOR
PROVIDENCE RI
02903-4141
US

IV. Provider business mailing address

1 HOPPIN ST 3RD FLOOR
PROVIDENCE RI
02903-4141
US

V. Phone/Fax

Practice location:
  • Phone: 401-793-8400
  • Fax: 401-793-8402
Mailing address:
  • Phone: 401-793-8400
  • Fax: 401-793-8402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA000016
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: