Provider Demographics
NPI:1912198201
Name:BUCKNER, ADAIR RUTHERFORD I (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:ADAIR
Middle Name:RUTHERFORD
Last Name:BUCKNER
Suffix:I
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 W HEATHER ST
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-2677
Mailing Address - Country:US
Mailing Address - Phone:909-875-4286
Mailing Address - Fax:
Practice Address - Street 1:775 W HEATHER ST
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-2677
Practice Address - Country:US
Practice Address - Phone:909-875-4286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA1181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant