Provider Demographics
NPI:1063512184
Name:BUCKWALTER, JOHN ELWIN (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ELWIN
Last Name:BUCKWALTER
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20548 N DONITHAN WAY
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-2466
Mailing Address - Country:US
Mailing Address - Phone:520-858-6181
Mailing Address - Fax:866-624-8718
Practice Address - Street 1:2902 W CLARENDON AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85017-4609
Practice Address - Country:US
Practice Address - Phone:520-858-6181
Practice Address - Fax:866-624-8718
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7376363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ969114Medicaid