Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | LL30988 | SC |
N | 2080P0202X | Pediatric Cardiologist | 30988 | SC |
Y | 2080P0203X | Pediatric Critical Care Doctor | 30988 | SC |
NPI | 1023277761 |
---|---|
Provider Name | Jason Robert Buckley |
First Address | Charlotte, NC 28275-1461 |
Second Address | Charleston, SC 29425-8908 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/06/2008 |
Last Update Date | 24/10/2017 |