Provider Demographics
NPI:1790872497
Name:TICKNER, ANTHONY J (DPM)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:J
Last Name:TICKNER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:MA
Mailing Address - Zip Code:01749-1855
Mailing Address - Country:US
Mailing Address - Phone:978-562-2155
Mailing Address - Fax:978-562-2640
Practice Address - Street 1:439 MAIN ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:MA
Practice Address - Zip Code:01749-1855
Practice Address - Country:US
Practice Address - Phone:978-562-2155
Practice Address - Fax:978-562-2640
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2317213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0714763Medicaid
MAV12265Medicare UPIN