Provider Demographics
NPI:1205847373
Name:BUCKLAND, AUDREY S (PA)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:S
Last Name:BUCKLAND
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 1:920 W IRONWOOD DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2463
Mailing Address - Country:US
Mailing Address - Phone:208-667-4557
Mailing Address - Fax:208-765-2887
Practice Address - Street 1:920 W IRONWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2463
Practice Address - Country:US
Practice Address - Phone:208-667-4557
Practice Address - Fax:208-765-2887
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMB2925735OtherDEA LICENSE