Provider Demographics
NPI:1659019222
Name:BUCKNER, DEREK BARKER (PT)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:BARKER
Last Name:BUCKNER
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:PO BOX 25537
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0537
Mailing Address - Country:US
Mailing Address - Phone:801-753-4371
Mailing Address - Fax:
Practice Address - Street 1:3249 N 1200 W
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-9772
Practice Address - Country:US
Practice Address - Phone:801-753-4371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12696815-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist