Provider Demographics
NPI:1578506846
Name:BUCKLEY, ELISE ANNA (NP)
Entity Type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:ANNA
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-355-6021
Mailing Address - Fax:617-730-0092
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-355-6021
Practice Address - Fax:617-730-0092
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002924363LP0200X
MA235121207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q58708Medicare UPIN
CTQ58708Medicare UPIN
CT500001610Medicare ID - Type Unspecified