Provider Demographics
NPI:1891840179
Name:BRATHEN BUCKLEW, KARI M (RPT)
Entity type:Individual
Prefix:
First Name:KARI
Middle Name:M
Last Name:BRATHEN BUCKLEW
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 N PERSHING AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6900
Mailing Address - Country:US
Mailing Address - Phone:209-957-4212
Mailing Address - Fax:209-957-5951
Practice Address - Street 1:4410 N PERSHING AVE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6900
Practice Address - Country:US
Practice Address - Phone:209-957-4212
Practice Address - Fax:209-957-5951
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23462225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ06573Medicare UPIN
CAOPT234620Medicare ID - Type Unspecified