Provider Demographics
NPI:1790331304
Name:TUCKER, DEREK WILLIAM
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:WILLIAM
Last Name:TUCKER
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 1:33 LAURENBURG DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-5197
Mailing Address - Country:US
Mailing Address - Phone:912-507-8021
Mailing Address - Fax:
Practice Address - Street 1:110 PROFESSIONAL CT
Practice Address - Street 2:
Practice Address - City:JESUP
Practice Address - State:GA
Practice Address - Zip Code:31545-0044
Practice Address - Country:US
Practice Address - Phone:912-427-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-11
Last Update Date:2019-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant