Provider Demographics
NPI:1598016610
Name:TUCKER, KATE COURTNEY (PA)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:COURTNEY
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5533
Mailing Address - Country:US
Mailing Address - Phone:229-227-1595
Mailing Address - Fax:229-227-1385
Practice Address - Street 1:334 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5533
Practice Address - Country:US
Practice Address - Phone:229-227-1595
Practice Address - Fax:229-227-1385
Is Sole Proprietor?:No
Enumeration Date:2012-09-28
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006641363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant