Provider Demographics
NPI:1477003127
Name:BENJAMIN, TUCKER J (ATS)
Entity Type:Individual
Prefix:
First Name:TUCKER
Middle Name:J
Last Name:BENJAMIN
Suffix:
Gender:M
Credentials:ATS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W11052 457TH AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:WI
Mailing Address - Zip Code:54021-7657
Mailing Address - Country:US
Mailing Address - Phone:651-890-7110
Mailing Address - Fax:
Practice Address - Street 1:W11052 457TH AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:WI
Practice Address - Zip Code:54021-7657
Practice Address - Country:US
Practice Address - Phone:651-890-7110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer