Provider Demographics
NPI:1184359713
Name:BUCKINGHAM, GREGORY ROBERT (MSN, AGACNP-BC)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ROBERT
Last Name:BUCKINGHAM
Suffix:
Gender:M
Credentials:MSN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:5255 E STOP 11 RD STE 300
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-6341
Practice Address - Country:US
Practice Address - Phone:317-528-4723
Practice Address - Fax:317-528-4699
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN71012765B363LA2100X
IN71012765A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care