Provider Demographics
NPI:1891462198
Name:BUCKLEY, EVAN JAMES (PTA)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:JAMES
Last Name:BUCKLEY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 N CROSSCREEK DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-1898
Mailing Address - Country:US
Mailing Address - Phone:480-694-2965
Mailing Address - Fax:
Practice Address - Street 1:15810 S 42ND ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7409
Practice Address - Country:US
Practice Address - Phone:480-759-0358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPTA-010838225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant