Provider Demographics
NPI:1568780179
Name:BRUCKNER, DARA (RPAC)
Entity Type:Individual
Prefix:MS
First Name:DARA
Middle Name:
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BROKAW LANE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11023
Mailing Address - Country:US
Mailing Address - Phone:516-551-8827
Mailing Address - Fax:
Practice Address - Street 1:17 BROKAW LANE
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11023
Practice Address - Country:US
Practice Address - Phone:516-551-8827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013953363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant