Provider Demographics
NPI:1922155043
Name:BUCKMIER, SHANNON MARIE (PT)
Entity type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:MARIE
Last Name:BUCKMIER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3244 51ST ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7179
Mailing Address - Country:US
Mailing Address - Phone:013-565-4127
Mailing Address - Fax:701-356-5412
Practice Address - Street 1:3244 51ST ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7179
Practice Address - Country:US
Practice Address - Phone:013-565-4127
Practice Address - Fax:701-356-5412
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND9802251P0200X
MN67422251P0200X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
64-05521OtherMEDICA-UNITED HEALTH CARE
ND54984Medicaid
HP50727OtherHEALTH PARTNERS
ND25303OtherBLUE CROSS BLUE SHIELD
64-05521OtherAETNA
MN736122000Medicaid
9378588OtherPRIVATE HEALTHCARE SYSTEM