Provider Demographics
NPI:1679900922
Name:BUCKINGHAM, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BUCKINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 WELLNESS WAY
Mailing Address - Street 2:BOX 410
Mailing Address - City:NEAH BAY
Mailing Address - State:WA
Mailing Address - Zip Code:98357
Mailing Address - Country:US
Mailing Address - Phone:360-645-2075
Mailing Address - Fax:
Practice Address - Street 1:100 WELLNESS WAY
Practice Address - Street 2:BOX 410
Practice Address - City:NEAH BAY
Practice Address - State:WA
Practice Address - Zip Code:98357
Practice Address - Country:US
Practice Address - Phone:360-645-2075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACM60387748363A00000X
WAPC60387753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant