Provider Demographics
NPI:1750388658
Name:BUCKREIS, FRED EDWARD (CRNA)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:EDWARD
Last Name:BUCKREIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 26TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3854
Mailing Address - Country:US
Mailing Address - Phone:814-942-2003
Mailing Address - Fax:814-949-3304
Practice Address - Street 1:909 26TH AVE
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-3854
Practice Address - Country:US
Practice Address - Phone:814-942-2003
Practice Address - Fax:814-949-3304
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN218355L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAR78624Medicare UPIN
PA001302Medicare ID - Type Unspecified