Provider Demographics
NPI:1932495876
Name:BUCKLEY, CHRISTINE CLARA
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:CLARA
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 WASHINGTON ST STE 106
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4071
Mailing Address - Country:US
Mailing Address - Phone:315-786-2000
Mailing Address - Fax:315-786-2899
Practice Address - Street 1:826 WASHINGTON ST STE 106
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4071
Practice Address - Country:US
Practice Address - Phone:315-786-2000
Practice Address - Fax:315-786-2899
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF336832-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
J400050111Medicare PIN