Provider Demographics
NPI:1548835341
Name:SUKUP, GINA MARIE (PTA, LMT)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:MARIE
Last Name:SUKUP
Suffix:
Gender:F
Credentials:PTA, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 BRADFORD ST
Mailing Address - Street 2:
Mailing Address - City:SEWARD
Mailing Address - State:NE
Mailing Address - Zip Code:68434-1708
Mailing Address - Country:US
Mailing Address - Phone:402-643-0711
Mailing Address - Fax:
Practice Address - Street 1:510 BRADFORD ST
Practice Address - Street 2:
Practice Address - City:SEWARD
Practice Address - State:NE
Practice Address - Zip Code:68434-1708
Practice Address - Country:US
Practice Address - Phone:402-643-0711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1799225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant