Provider Demographics
NPI:1801582481
Name:BUKE, IDRIS (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:IDRIS
Middle Name:
Last Name:BUKE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HERRELL RD
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-5527
Mailing Address - Country:US
Mailing Address - Phone:770-292-0926
Mailing Address - Fax:
Practice Address - Street 1:20 HERRELL RD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-5527
Practice Address - Country:US
Practice Address - Phone:770-812-3266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN2164202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry