Provider Demographics
NPI:1619477031
Name:STUCKER, MARK TODD
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:TODD
Last Name:STUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 E 5TH AVE # 2253
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1309
Mailing Address - Country:US
Mailing Address - Phone:509-242-2308
Mailing Address - Fax:509-455-4988
Practice Address - Street 1:12 E 5TH AVE # 2253
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1309
Practice Address - Country:US
Practice Address - Phone:509-242-2308
Practice Address - Fax:509-455-4988
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60538209175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist