Provider Demographics
NPI:1346222056
Name:BUCK, BRIAN GORDON (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:GORDON
Last Name:BUCK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 73709
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30271-3709
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:
Practice Address - Street 1:705 DIXIE ST
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-3818
Practice Address - Country:US
Practice Address - Phone:770-812-5730
Practice Address - Fax:770-838-8563
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN099295367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA491431789AMedicaid
GA000578586CMedicaid
GA43BBBBCMedicare PIN
GA491431789AMedicaid
GAGRP6182Medicare PIN