Provider Demographics
NPI:1477930154
Name:BUCASAS, PETER ANDRE (PT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:ANDRE
Last Name:BUCASAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16170 KINGSPORT RD
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-5602
Mailing Address - Country:US
Mailing Address - Phone:708-326-1550
Mailing Address - Fax:
Practice Address - Street 1:176 THOMAS CT
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-2451
Practice Address - Country:US
Practice Address - Phone:847-526-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070017306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist