Provider Demographics
NPI:1972105898
Name:BUCKLEY, ALYSSA SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:SHANNON
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-358-4000
Mailing Address - Fax:210-358-0647
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-4000
Practice Address - Fax:210-358-0647
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18258363A00000X
NY027233363AM0700X
PAMA062138363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical