Provider Demographics
NPI:1922155043
Name:BUCKMIER, SHANNON MARIE (PT)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:MARIE
Last Name:BUCKMIER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 11TH ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-6048
Mailing Address - Country:US
Mailing Address - Phone:701-730-6202
Mailing Address - Fax:
Practice Address - Street 1:3001 11TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6048
Practice Address - Country:US
Practice Address - Phone:701-351-6202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9802251P0200X
MN67422251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP50727OtherHEALTH PARTNERS
64-05521OtherMEDICA-UNITED HEALTH CARE
MN736122000Medicaid
9378588OtherPRIVATE HEALTHCARE SYSTEM
ND25303OtherBLUE CROSS BLUE SHIELD
ND54984Medicaid
64-05521OtherAETNA