Provider Demographics
NPI:1093796062
Name:HUTTO, TARA R (DPT)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:R
Last Name:HUTTO
Suffix:
Gender:F
Credentials:DPT
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 7208
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7208
Mailing Address - Country:US
Mailing Address - Phone:270-415-9575
Mailing Address - Fax:270-415-9576
Practice Address - Street 1:5150 VILLAGE SQUARE DR
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-9060
Practice Address - Country:US
Practice Address - Phone:270-415-9575
Practice Address - Fax:270-415-9576
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT002077225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000288348OtherANTHEM
KY1109154002OtherCIGNA
KY650023686Medicare PIN
KYP63107Medicare UPIN
KY0567803Medicare PIN
KY000000288348OtherANTHEM
KY5004908Medicare PIN