1124432950 NPI number — RYAN BUCKLEY PA

Table of content: RYAN BUCKLEY PA (NPI 1124432950)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124432950 NPI number — RYAN BUCKLEY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUCKLEY
Provider First Name:
RYAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124432950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 TROY SCHENECTADY RD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
LATHAM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12110-2442
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-782-3700
Provider Business Mailing Address Fax Number:
518-782-3799

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1735 ROUTE 9
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLIFTON PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12065-2421
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-371-5437
Provider Business Practice Location Address Fax Number:
518-383-6737
Provider Enumeration Date:
06/19/2014

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:  017584 , 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: 03925775 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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