Active NPI
Mary Bucknam, P.A.
- Medical Physician Assistant
- Ithaca, NY
National Provider Identifier
1104906726
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Physician Assistant
- License
- 0032601
- Practice address
- 1301 Trumansburg Rd
Suite H
Ithaca, NY 14850-1397 - Phone
- (607) 272-6880
- Fax
- (607) 272-1436
- NPI assigned
- Oct 17, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | 0032601 | NY | Primary |
Addresses
Primary practice location
1301 Trumansburg Rd
Suite H
Ithaca, NY 14850-1397
Mailing address
1301 Trumansburg Rd
Suite H
Ithaca, NY 14850-1397
Phone (607) 272-6880
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 02060933 | Medicaid | NY |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0032601 | NY | MD | Medical Physician Assistant |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Buttermilk Falls Pediatrics | Past | Accepting new patients | |
| Cornell University | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Pediatrics Physician
- Ithaca, NY
- NPI 1316036635
-
- Student Health Clinic/Center
- Ithaca, NY
- NPI 1073584926
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1161043200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1104906726",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1301 TRUMANSBURG RD",
"address_2": "SUITE H",
"city": "ITHACA",
"state": "NY",
"postal_code": "148501397",
"telephone_number": "607-272-6880",
"fax_number": "607-272-1436"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1301 TRUMANSBURG RD",
"address_2": "SUITE H",
"city": "ITHACA",
"state": "NY",
"postal_code": "148501397",
"telephone_number": "607-272-6880",
"fax_number": "607-272-1436"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BUCKNAM",
"first_name": "MARY",
"credential": "P.A.",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-10-17",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "NY",
"license": "0032601",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "02060933",
"state": "NY"
}
],
"endpoints": [],
"other_names": []
}Other providers in Ithaca, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.