Provider Demographics
NPI:1487200473
Name:BUCKO, ANDREW PAUL (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:PAUL
Last Name:BUCKO
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PASADENA DR
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:NJ
Mailing Address - Zip Code:08049-1645
Mailing Address - Country:US
Mailing Address - Phone:610-717-8755
Mailing Address - Fax:
Practice Address - Street 1:205 S PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:PA
Practice Address - Zip Code:19086-6333
Practice Address - Country:US
Practice Address - Phone:610-892-3470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-14
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAJ3-00005122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000015396OtherBOC
PAJ3-0000512OtherSTATE ATHLETIC TRAINING LICENSE