Provider Demographics
NPI:1649247651
Name:GLEASON, PAUL JOHN (PT)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:JOHN
Last Name:GLEASON
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 1:375 E VIRGINIA AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1220
Mailing Address - Country:US
Mailing Address - Phone:602-264-5323
Mailing Address - Fax:602-264-5302
Practice Address - Street 1:375 E VIRGINIA AVE
Practice Address - Street 2:SUITE B
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85004-1220
Practice Address - Country:US
Practice Address - Phone:602-264-5323
Practice Address - Fax:602-264-5302
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0656225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ781387Medicaid
AZ781387Medicaid