Provider Demographics
NPI:1083279723
Name:BUCKLEY, LAURA (PA-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 DEMOCRACY ST APT 108
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-5672
Mailing Address - Country:US
Mailing Address - Phone:757-897-7507
Mailing Address - Fax:
Practice Address - Street 1:99 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1787
Practice Address - Country:US
Practice Address - Phone:541-482-7799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA192432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant