Provider Demographics
NPI:1356391882
Name:RUCKER, THERESA RENEE (PA)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:RENEE
Last Name:RUCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:RUCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:1291 HARBOR TOWN CIR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-1912
Mailing Address - Country:US
Mailing Address - Phone:321-757-0409
Mailing Address - Fax:
Practice Address - Street 1:2900 VETERANS WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-8007
Practice Address - Country:US
Practice Address - Phone:321-637-3788
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2203363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical