Provider Demographics
NPI:1093109092
Name:BUCHANAN, KRISTA R
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:R
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 961
Mailing Address - Street 2:
Mailing Address - City:EFFORT
Mailing Address - State:PA
Mailing Address - Zip Code:18330-0961
Mailing Address - Country:US
Mailing Address - Phone:570-656-4047
Mailing Address - Fax:
Practice Address - Street 1:1002 CUB CT
Practice Address - Street 2:
Practice Address - City:EFFORT
Practice Address - State:PA
Practice Address - Zip Code:18330-8035
Practice Address - Country:US
Practice Address - Phone:570-656-4047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA3975912235500000X, 235Z00000X, 252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No235500000XSpeech, Language and Hearing Service ProvidersSpecialist/Technologist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0421880137-8OtherPROFESIONAL INSURANCE POLICY NUMBER
PA0421880137-8OtherINSURANCE POLICY IDENTIFYING NUMBER