Provider Demographics
NPI:1174173066
Name:BUXMAN, TIMOTHY AUSTIN
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:AUSTIN
Last Name:BUXMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11490 DOUBLE T LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:MO
Mailing Address - Zip Code:63044-2901
Mailing Address - Country:US
Mailing Address - Phone:314-973-6008
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-9912
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0363LN0000X
MO2016014841163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive CareGroup - Single Specialty
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Single Specialty