Provider Demographics
NPI:1104906726
Name:BUCKNAM, MARY (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:BUCKNAM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:1301 TRUMANSBURG RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1397
Mailing Address - Country:US
Mailing Address - Phone:607-272-6880
Mailing Address - Fax:607-272-1436
Practice Address - Street 1:1301 TRUMANSBURG RD
Practice Address - Street 2:SUITE H
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1397
Practice Address - Country:US
Practice Address - Phone:607-272-6880
Practice Address - Fax:607-272-1436
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY0032601363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02060933Medicaid