Provider Demographics
NPI:1710221320
Name:TUCKER, GARRY LANE (PT)
Entity Type:Individual
Prefix:MR
First Name:GARRY
Middle Name:LANE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 MOORMAN LN
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-0711
Mailing Address - Country:US
Mailing Address - Phone:270-792-1261
Mailing Address - Fax:
Practice Address - Street 1:813 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42210-9009
Practice Address - Country:US
Practice Address - Phone:270-597-2335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0036182251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics