Basic Information
| Provider Information | |||||||||
| NPI: | 1578537296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCKLES | ||||||||
| FirstName: | ROSS | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2214 CANTERBURY DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | HAYS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676012375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856232360 | ||||||||
| FaxNumber: | 7856232371 | ||||||||
| Practice Location | |||||||||
| Address1: | 2214 CANTERBURY DR | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | HAYS | ||||||||
| State: | KS | ||||||||
| PostalCode: | 676012375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7856232360 | ||||||||
| FaxNumber: | 7856232371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 05-30122 | KS | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100454950A | 05 | KS | MEDICAID |