Basic Information
| Provider Information | |||||||||
| NPI: | 1649247651 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLEASON | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 E VIRGINIA AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022645323 | ||||||||
| FaxNumber: | 6022645302 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 E VIRGINIA AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022645323 | ||||||||
| FaxNumber: | 6022645302 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 0656 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | 0656 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | 0656 | AZ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | 781387 | 05 | AZ | MEDICAID |