Basic Information
| Provider Information | |||||||||
| NPI: | 1245466226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159054305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142695200 | ||||||||
| FaxNumber: | 8144727336 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 SCALP AVE | ||||||||
| Address2: | STE 1000 | ||||||||
| City: | JOHNSTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 159043321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8142695200 | ||||||||
| FaxNumber: | 8144727336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2009 | ||||||||
| LastUpdateDate: | 09/11/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA053843 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1007698380002 | 05 | PA | MEDICAID | 1007698380001 | 05 | PA | MEDICAID |