Provider Demographics
NPI:1700103140
Name:TUCKWILLER, ERICA JAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:JAYNE
Last Name:TUCKWILLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 MALLARD CT
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-3664
Mailing Address - Country:US
Mailing Address - Phone:304-255-0800
Mailing Address - Fax:304-255-1040
Practice Address - Street 1:30 MALLARD CT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3664
Practice Address - Country:US
Practice Address - Phone:304-255-0800
Practice Address - Fax:304-255-1040
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2703208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics