Provider Demographics
NPI:1730553512
Name:TUCKER, PHILLIP (ATC, LAT)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2609 SE 7TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-6776
Mailing Address - Country:US
Mailing Address - Phone:580-214-0782
Mailing Address - Fax:
Practice Address - Street 1:12613 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73170-6903
Practice Address - Country:US
Practice Address - Phone:405-735-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6952255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer