Provider Demographics
NPI:1841256039
Name:BUCKNOR, MICHELLE RENE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:RENE
Last Name:BUCKNOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENE
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1001 ROCK QUARRY RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-3825
Mailing Address - Country:US
Mailing Address - Phone:919-833-3111
Mailing Address - Fax:919-834-3118
Practice Address - Street 1:1011 ROCK QUARRY RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-3825
Practice Address - Country:US
Practice Address - Phone:919-833-3111
Practice Address - Fax:919-834-3118
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS104778208000000X
KS04-24685208000000X
NC2015-01972208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100147720BMedicaid
NC2015-01972OtherMEDICAL LICENSE
NCBH3827790OtherDEA
NCNCQ521EMedicare PIN
KS100147720BMedicaid
NCNCQ521DMedicare PIN
NCNCQ521CMedicare PIN
NCBH3827790OtherDEA
NCNCQ521BMedicare PIN