Basic Information
| Provider Information | |||||||||
| NPI: | 1114485067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKEY | ||||||||
| FirstName: | CARISSA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5859 W TALAVI BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022987777 | ||||||||
| FaxNumber: | 6239306060 | ||||||||
| Practice Location | |||||||||
| Address1: | 5859 W TALAVI BLVD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853061870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022987777 | ||||||||
| FaxNumber: | 6239306060 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2019 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP11492 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.