Provider Demographics
NPI:1659142602
Name:TUCKER, ETHAN (DPT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:PA
Mailing Address - Zip Code:17268-2323
Mailing Address - Country:US
Mailing Address - Phone:717-765-3456
Mailing Address - Fax:
Practice Address - Street 1:500 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:PA
Practice Address - Zip Code:17268-2323
Practice Address - Country:US
Practice Address - Phone:717-765-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT031639225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist