Provider Demographics
NPI:1396230058
Name:BUCHANAN, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 N CRESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-2536
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4804 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-5023
Practice Address - Country:US
Practice Address - Phone:605-759-5198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDMT11442225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist