Provider Demographics
NPI:1871665208
Name:BUCK, MARY ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BUCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:YATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1139 LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5502
Mailing Address - Country:US
Mailing Address - Phone:912-303-4200
Mailing Address - Fax:912-790-2701
Practice Address - Street 1:1139 LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-5502
Practice Address - Country:US
Practice Address - Phone:912-303-4200
Practice Address - Fax:912-790-2701
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA072464363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBHNCOtherMEDICARE PTAN
GA000818133BMedicaid
GA000818133BMedicaid