Provider Demographics
NPI:1497026157
Name:BUCKNER, DIANA ANGELA (PTA)
Entity type:Individual
Prefix:MS
First Name:DIANA
Middle Name:ANGELA
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4254 PIRATES BCH
Mailing Address - Street 2:
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77554-8055
Mailing Address - Country:US
Mailing Address - Phone:817-932-4505
Mailing Address - Fax:
Practice Address - Street 1:4254 PIRATES BCH
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77554-8055
Practice Address - Country:US
Practice Address - Phone:817-932-4505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2054319225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant