Provider Demographics
NPI:1215518675
Name:RUCKER, TAMALA C (DOO)
Entity type:Individual
Prefix:
First Name:TAMALA
Middle Name:C
Last Name:RUCKER
Suffix:
Gender:F
Credentials:DOO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PRESCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18510-2315
Mailing Address - Country:US
Mailing Address - Phone:570-239-4604
Mailing Address - Fax:
Practice Address - Street 1:505 PRESCOTT AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2315
Practice Address - Country:US
Practice Address - Phone:570-239-4604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-17
Last Update Date:2021-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy