Provider Demographics
NPI:1235246489
Name:RUCKER, SUZANNE ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:ELIZABETH
Last Name:RUCKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 JOHN EVANS DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-3638
Mailing Address - Country:US
Mailing Address - Phone:228-326-7006
Mailing Address - Fax:
Practice Address - Street 1:9471 THREE RIVERS RD
Practice Address - Street 2:STE D
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4230
Practice Address - Country:US
Practice Address - Phone:228-822-9066
Practice Address - Fax:228-822-9722
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3556225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04178840Medicaid