Provider Demographics
NPI:1871500165
Name:BUCKLEY, JACQUELYN A (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:A
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELYN
Other - Middle Name:A
Other - Last Name:DELISLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:1299 ROUTE 9
Practice Address - Street 2:
Practice Address - City:GANSEVOORT
Practice Address - State:NY
Practice Address - Zip Code:12831-1560
Practice Address - Country:US
Practice Address - Phone:518-761-6961
Practice Address - Fax:518-761-1006
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03160905Medicaid
NYQ57136Medicare UPIN
NYPA1137Medicare ID - Type Unspecified