Provider Demographics
NPI:1700266558
Name:PARKER, BUCKLEY (PA)
Entity type:Individual
Prefix:
First Name:BUCKLEY
Middle Name:
Last Name:PARKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38302-0400
Mailing Address - Country:US
Mailing Address - Phone:731-425-5752
Mailing Address - Fax:731-425-5783
Practice Address - Street 1:87 MURRAY GUARD DR STE B
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3775
Practice Address - Country:US
Practice Address - Phone:731-664-1375
Practice Address - Fax:731-660-8319
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2797363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ014229Medicaid
TN103I970449Medicare PIN