Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 01077239A | IN |
NPI | 1346463205 |
---|---|
Provider Name | Rebecca Suzanna King-Tucker |
First Address | Terre Haute, IN 47802-4114 |
Second Address | Terre Haute, IN 47802-4114 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2007 |
Last Update Date | 02/11/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
011003081 | MEDICARE PTAN (01) | |
171576 | OREGON MEDICAL LICENSE (01) | OR |
500628245 | (05) | OR |
G97361 | (02) |