Basic Information
| Provider Information | |||||||||
| NPI: | 1679900922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCKINGHAM | ||||||||
| FirstName: | BRIAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 WELLNESS WAY | ||||||||
| Address2: | BOX 410 | ||||||||
| City: | NEAH BAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606452075 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 WELLNESS WAY | ||||||||
| Address2: | BOX 410 | ||||||||
| City: | NEAH BAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606452075 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 10/02/2013 | ||||||||
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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 | 363A00000X | CM60387748 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PC60387753 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.