Healthcare Provider Details

I. General information

NPI: 1487200473
Provider Name (Legal Business Name): ANDREW PAUL BUCKO ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 S PROVIDENCE RD
WALLINGFORD PA
19086-6333
US

IV. Provider business mailing address

500 PASADENA DR
MAGNOLIA NJ
08049-1645
US

V. Phone/Fax

Practice location:
  • Phone: 610-892-3470
  • Fax:
Mailing address:
  • Phone: 610-717-8755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberJ3-0000512
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2000015396
Identifier TypeOTHER
Identifier State
Identifier IssuerBOC
# 2
IdentifierJ3-0000512
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerSTATE ATHLETIC TRAINING LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: