Provider Demographics
NPI:1689090474
Name:BUCKINGHAM, BRANDIE ROSE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BRANDIE
Middle Name:ROSE
Last Name:BUCKINGHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1300 BAXTER ST
Mailing Address - Street 2:STE 215
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3053
Mailing Address - Country:US
Mailing Address - Phone:704-332-0396
Mailing Address - Fax:704-971-0035
Practice Address - Street 1:2711 RANDOLPH RD
Practice Address - Street 2:BLDG 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2034
Practice Address - Country:US
Practice Address - Phone:704-348-2992
Practice Address - Fax:704-971-0035
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-04904363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1852PAMedicaid
NC1689090474Medicaid
NC1689090474Medicaid
SC1852PAMedicaid