Basic Information
| Provider Information | |||||||||
| NPI: | 1104852094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCKNER | ||||||||
| FirstName: | KAITLIN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 MAIN ST STE 190 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551123271 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6124542046 | ||||||||
| FaxNumber: | 6124542046 | ||||||||
| Practice Location | |||||||||
| Address1: | 6043 HUDSON RD STE 220 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551251033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519258200 | ||||||||
| FaxNumber: | 6519258201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 10/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 6669778-1206 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3127 | AZ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 1414 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 10495 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 20047220A | 05 | OK | MEDICAID |