Provider Demographics
NPI:1255511036
Name:ANAYA, SAMUEL T (PT DPT OCS MTC)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:T
Last Name:ANAYA
Suffix:
Gender:M
Credentials:PT DPT OCS MTC
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:T
Other - Last Name:ANAYA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-1980
Mailing Address - Fax:630-928-5080
Practice Address - Street 1:6970 N ORACLE RD STE 130
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-4237
Practice Address - Country:US
Practice Address - Phone:520-219-5825
Practice Address - Fax:520-219-5827
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2414208100000X
AZLPT-002414225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZRPT2414Medicare PIN