Provider Demographics
NPI:1871279745
Name:BOSQUEZ, LUCAS ALLEN (PTA)
Entity type:Individual
Prefix:
First Name:LUCAS
Middle Name:ALLEN
Last Name:BOSQUEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2306 GRAND VIEW DR EAST
Mailing Address - Street 2:
Mailing Address - City:GARDEN
Mailing Address - State:KS
Mailing Address - Zip Code:67846-6784
Mailing Address - Country:US
Mailing Address - Phone:785-531-9642
Mailing Address - Fax:
Practice Address - Street 1:401 E SPRUCE ST
Practice Address - Street 2:
Practice Address - City:GARDEN
Practice Address - State:KS
Practice Address - Zip Code:67846
Practice Address - Country:US
Practice Address - Phone:620-272-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-03307225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant