Basic Information
| Provider Information | |||||||||
| NPI: | 1437731353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCHEK | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 S WEST ST | ||||||||
| Address2: | |||||||||
| City: | HOMER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130771542 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533797 | ||||||||
| FaxNumber: | 6077536677 | ||||||||
| Practice Location | |||||||||
| Address1: | 24 GROTON AVE | ||||||||
| Address2: | |||||||||
| City: | CORTLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130452014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077533774 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2021 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 027063 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 06743026 | 05 | NY | MEDICAID |