Provider Demographics
NPI:1841296555
Name:BUCKLIN, LISA M (CNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:BUCKLIN
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-2312
Mailing Address - Country:US
Mailing Address - Phone:605-698-7681
Mailing Address - Fax:605-698-3493
Practice Address - Street 1:205 ORCHARD DR
Practice Address - Street 2:
Practice Address - City:SISSETON
Practice Address - State:SD
Practice Address - Zip Code:57262-2312
Practice Address - Country:US
Practice Address - Phone:605-698-7681
Practice Address - Fax:605-698-3493
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR022487363L00000X
MNR-158898-7363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6823133Medicaid
MN630958500Medicaid
MN630958500Medicaid
MN500002228Medicare ID - Type Unspecified
SD6823133Medicaid