Provider Demographics
NPI:1093109803
Name:BUCKINGHAM, LAUREN DUANE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:DUANE
Last Name:BUCKINGHAM
Suffix:
Gender:M
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 1:2025 E BELTLINE AVE SE STE 310
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7634
Mailing Address - Country:US
Mailing Address - Phone:616-942-2222
Mailing Address - Fax:
Practice Address - Street 1:2300 N EDWARD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-4163
Practice Address - Country:US
Practice Address - Phone:217-876-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-19
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.005383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant