Provider Demographics
NPI:1144222704
Name:BUCKLEW, PASQUA ROSE (CNM)
Entity Type:Individual
Prefix:
First Name:PASQUA
Middle Name:ROSE
Last Name:BUCKLEW
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 FISHER STREET
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39534
Mailing Address - Country:US
Mailing Address - Phone:228-376-4879
Mailing Address - Fax:228-376-0172
Practice Address - Street 1:301 FISHER STREET
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39534
Practice Address - Country:US
Practice Address - Phone:228-376-4879
Practice Address - Fax:228-376-0172
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR549533367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00123966Medicaid
MSS20493Medicare UPIN
MS420000037Medicare ID - Type Unspecified