Provider Demographics
NPI:1861902546
Name:TAECKER, PAMELA (PTA)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:TAECKER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2225 HEAVENLY VIEW TRL
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-6887
Mailing Address - Country:US
Mailing Address - Phone:843-250-7386
Mailing Address - Fax:
Practice Address - Street 1:3050 N ORMSBY BLVD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-8378
Practice Address - Country:US
Practice Address - Phone:775-841-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVA-1055208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation