Provider Demographics
NPI:1093783524
Name:WILSON, BUCKEY LYN (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:BUCKEY
Middle Name:LYN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 N MCKINLEY RD
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1836
Mailing Address - Country:US
Mailing Address - Phone:847-370-0624
Mailing Address - Fax:
Practice Address - Street 1:1717 17TH ST
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-2052
Practice Address - Country:US
Practice Address - Phone:847-578-7400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer