Basic Information
| Provider Information | |||||||||
| NPI: | 1619082351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKINGHAM | ||||||||
| FirstName: | ULISA | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUCKINGHAM | ||||||||
| OtherFirstName: | U. | ||||||||
| OtherMiddleName: | DIANE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 25173 | ||||||||
| Address2: | |||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662255173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137911292 | ||||||||
| FaxNumber: | 9134696440 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 MAINE ST | ||||||||
| Address2: | BERT NASH | ||||||||
| City: | LAWRENCE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660441368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7858439192 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 04/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 04-23312 | KS | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 20-2932962 | 01 | KS | FEDERAL TAX ID | OTHER |