Provider Demographics
NPI:1073897914
Name:BUCK, KAITLYN J (PA)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:J
Last Name:BUCK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 ROUTE 17M
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:NY
Mailing Address - Zip Code:10924-5210
Mailing Address - Country:US
Mailing Address - Phone:845-294-0661
Mailing Address - Fax:845-360-9339
Practice Address - Street 1:2004 ROUTE 17M
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-5210
Practice Address - Country:US
Practice Address - Phone:845-294-0661
Practice Address - Fax:845-818-9646
Is Sole Proprietor?:No
Enumeration Date:2011-10-10
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015142-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical