Provider Demographics
NPI:1356330542
Name:BUCKLEY, LARRY R (PA-C, MPA)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:R
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:PA-C, MPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:600 BLUES LAKE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8022
Mailing Address - Country:US
Mailing Address - Phone:573-364-8823
Mailing Address - Fax:573-341-5969
Practice Address - Street 1:600 BLUES LAKE PKWY
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-8022
Practice Address - Country:US
Practice Address - Phone:573-364-8822
Practice Address - Fax:573-341-5969
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO112148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant