Provider Demographics
NPI:1588229819
Name:BUCKNER, GARRETT (BA, MA)
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:BA, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 THUNDER RD
Mailing Address - Street 2:
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4423
Mailing Address - Country:US
Mailing Address - Phone:631-513-1324
Mailing Address - Fax:
Practice Address - Street 1:299 HALLOCK AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFF STA
Practice Address - State:NY
Practice Address - Zip Code:11776-1217
Practice Address - Country:US
Practice Address - Phone:314-734-4284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist