Provider Demographics
NPI:1245466226
Name:TUCKER, EMILY ROSE (PA)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ROSE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1086 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-4305
Mailing Address - Country:US
Mailing Address - Phone:814-269-5200
Mailing Address - Fax:814-472-7336
Practice Address - Street 1:1450 SCALP AVE
Practice Address - Street 2:STE 1000
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904-3321
Practice Address - Country:US
Practice Address - Phone:814-269-5200
Practice Address - Fax:814-472-7336
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053843363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007698380002Medicaid
PA1007698380001Medicaid
PA163146EWSMedicare PIN
PA393821Medicare PIN
PA1007698380002Medicaid
PA1007698380001Medicaid