Healthcare Provider Details

I. General information

NPI: 1467936336
Provider Name (Legal Business Name): ZACHARY TYLER BUCKNER BSN-RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2018
Last Update Date: 10/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1278 N LAFAYETTE DR
SUMTER SC
29150-2964
US

IV. Provider business mailing address

1278 N LAFAYETTE DR
SUMTER SC
29150-2964
US

V. Phone/Fax

Practice location:
  • Phone: 803-774-4500
  • Fax: 803-774-4626
Mailing address:
  • Phone: 803-774-4500
  • Fax: 803-774-4626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number232066
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: