Provider Demographics
NPI:1013155860
Name:TUPPER, SUE ANN (PTA)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:ANN
Last Name:TUPPER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 FLORADALE RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-5622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7571 STATE ROUTE 54
Practice Address - Street 2:REHAB SERVICES DEPT., IRA DAVENPORT MEMORIAL HOSPITAL
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-9504
Practice Address - Country:US
Practice Address - Phone:607-776-8880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-02
Last Update Date:2009-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005493-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant