Provider Demographics
NPI:1508258393
Name:BUCKLES, LINDSEY (PA)
Entity Type:Individual
Prefix:MRS
First Name:LINDSEY
Middle Name:
Last Name:BUCKLES
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 1:261 COVENTRY PL
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-1507
Mailing Address - Country:US
Mailing Address - Phone:618-946-0299
Mailing Address - Fax:618-498-8439
Practice Address - Street 1:903 S STATE ST
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2344
Practice Address - Country:US
Practice Address - Phone:618-639-9255
Practice Address - Fax:618-639-8100
Is Sole Proprietor?:No
Enumeration Date:2015-03-03
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015007736363A00000X
IL085007107363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1508258393Medicaid