Provider Demographics
NPI:1154741742
Name:BUCKNER, AMANDA (PA)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE - BOX 656
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:158 SAWGRASS DR
Practice Address - Street 2:FLOOR 2
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-4648
Practice Address - Country:US
Practice Address - Phone:585-275-2838
Practice Address - Fax:585-756-5457
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005391363AM0700X
OH004019363AM0700X
NY19177363AM0700X
NY019177363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04428075Medicaid
NY04428075Medicaid