Basic Information
| Provider Information | |||||||||
| NPI: | 1902986680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUCKMAN | ||||||||
| FirstName: | PENELOPE | ||||||||
| MiddleName: | JOAN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 WARD CT | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292237321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037866446 | ||||||||
| FaxNumber: | 8034343855 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 MEDICAL PARK ROAD | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8034347320 | ||||||||
| FaxNumber: | 8034343855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | APN435 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | PNP003 | 05 | SC | MEDICAID |