1871500165 NPI number — JACQUELYN A BUCKLEY PA-C

Table of content: MS. IVY NICHELLE MILLS LPN (NPI 1649940552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871500165 NPI number — JACQUELYN A BUCKLEY PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLEY
Provider First Name:
JACQUELYN
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DELISLE
Provider Other First Name:
JACQUELYN
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871500165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9 CAREY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
QUEENSBURY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12804-7880
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-761-0300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1299 ROUTE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GANSEVOORT
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12831-1560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-761-6961
Provider Business Practice Location Address Fax Number:
518-761-1006
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  010844 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03160905 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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