Provider Demographics
NPI:1316206097
Name:TUCKER, CHRISTY L (PTA)
Entity Type:Individual
Prefix:
First Name:CHRISTY
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2860 I-55 SERVICE RD
Mailing Address - Street 2:STE C
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364
Mailing Address - Country:US
Mailing Address - Phone:870-739-8686
Mailing Address - Fax:870-739-8656
Practice Address - Street 1:2860 I-55 SERVICE RD
Practice Address - Street 2:STE C
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364
Practice Address - Country:US
Practice Address - Phone:870-739-8686
Practice Address - Fax:870-739-8656
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPTA2591225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR192038721Medicaid