Basic Information
| Provider Information | |||||||||
| NPI: | 1861868713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUCKER | ||||||||
| FirstName: | NOAH | ||||||||
| MiddleName: | SCOTT | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 PROVIDENCE RD STE 80 | ||||||||
| Address2: | |||||||||
| City: | VIRGINIA BEACH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 234644128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7574674604 | ||||||||
| FaxNumber: | 7574672716 | ||||||||
| Practice Location | |||||||||
| Address1: | 11490 ALPHARETTA HWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | ROSWELL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300763811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707408592 | ||||||||
| FaxNumber: | 7707529478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2015 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT011967 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.