Provider Demographics
NPI:1841207792
Name:BUCKNER, RANDY L (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDY
Middle Name:L
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1401 MARVIN RD NE
Mailing Address - Street 2:#307 PMB 266
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5709
Mailing Address - Country:US
Mailing Address - Phone:360-491-5055
Mailing Address - Fax:360-491-5890
Practice Address - Street 1:402 BLACK HILLS LN SW STE B
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8146
Practice Address - Country:US
Practice Address - Phone:360-754-4837
Practice Address - Fax:360-754-7304
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWAOP00001204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1106996Medicaid
WA0127421OtherL&I
WABU9119OtherREGENCE
WABU9119OtherREGENCE
WAAB08457Medicare ID - Type UnspecifiedMEDICARE