Provider Demographics
NPI:1225006430
Name:TUCKER, KENNETH A (PT)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:A
Last Name:TUCKER
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 1:711 D ST
Mailing Address - Street 2:#102
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3707
Mailing Address - Country:US
Mailing Address - Phone:415-456-3551
Mailing Address - Fax:415-457-7260
Practice Address - Street 1:711 D ST
Practice Address - Street 2:#102
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3707
Practice Address - Country:US
Practice Address - Phone:415-456-3551
Practice Address - Fax:415-457-7260
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT006218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-6366835OtherTAX ID#
CA94-6366835OtherTAX ID#