Healthcare Provider Details

I. General information

NPI: 1972105898
Provider Name (Legal Business Name): ALYSSA SHANNON BUCKLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-4000
  • Fax: 210-358-0647
Mailing address:
  • Phone: 210-358-4000
  • Fax: 210-358-0647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18258
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number027233
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA062138
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: