Provider Demographics
NPI:1609043827
Name:BUCKMASTER, MICHAEL RONALD (NP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RONALD
Last Name:BUCKMASTER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 S REED RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3838
Mailing Address - Country:US
Mailing Address - Phone:765-453-8666
Mailing Address - Fax:765-453-8506
Practice Address - Street 1:3505 S REED RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3838
Practice Address - Country:US
Practice Address - Phone:765-453-8666
Practice Address - Fax:765-453-8506
Is Sole Proprietor?:No
Enumeration Date:2008-05-15
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28142494A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200941760Medicaid
IN1609043827Medicare PIN