Individual
EMILY BUCKMILLER SUPERNOVA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
4001 DUTCHMANS LN, LOUISVILLE, KY 40207-4714
(502) 559-3930
(502) 559-4605
Mailing address
PO BOX 776879, CHICAGO, IL 60677-6879
(502) 588-9490
(502) 272-5116
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
10732519-1206
UT
363A00000X
Physician Assistant
2018013895
MO
363A00000X
Physician Assistant
Primary
PA2967
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
PA2967
STATE LICENSE
KY
Enumeration date
03/12/2018
Last updated
09/27/2022
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