Provider Demographics
NPI:1104852094
Name:BUCKNER, KAITLIN (PA)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:
Last Name:BUCKNER
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 1:550 MAIN ST STE 190
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-3271
Mailing Address - Country:US
Mailing Address - Phone:612-454-2046
Mailing Address - Fax:612-454-2046
Practice Address - Street 1:6043 HUDSON RD STE 220
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1033
Practice Address - Country:US
Practice Address - Phone:651-925-8200
Practice Address - Fax:651-925-8201
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6669778-1206363A00000X
AZ3127363A00000X
OK1414363A00000X
MN10495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20047220AMedicaid
OKQ41104Medicare UPIN
OK243511300Medicare ID - Type Unspecified