Provider Demographics
NPI:1649756586
Name:BUCKOSKI, MARYLIE (NP)
Entity Type:Individual
Prefix:
First Name:MARYLIE
Middle Name:
Last Name:BUCKOSKI
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 1:1629 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-0139
Mailing Address - Country:US
Mailing Address - Phone:501-541-3500
Mailing Address - Fax:
Practice Address - Street 1:141 RVG PKWY STE 101
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5289
Practice Address - Country:US
Practice Address - Phone:972-923-8923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-13
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005684363LF0000X
TX1059283363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily