Basic Information
| Provider Information | |||||||||
| NPI: | 1508258393 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKLES | ||||||||
| FirstName: | LINDSEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 261 COVENTRY PL | ||||||||
| Address2: | |||||||||
| City: | EDWARDSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620251507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189460299 | ||||||||
| FaxNumber: | 6184988439 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MAPLE SUMMIT RD | ||||||||
| Address2: | |||||||||
| City: | JERSEYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620522028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6184986402 | ||||||||
| FaxNumber: | 6184988439 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2015 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2015007736 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 085007107 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1508258393 | 05 | MO | MEDICAID |