Provider Demographics
NPI:1467281204
Name:TUCKER, ALEXIS PAMALA (ATC)
Entity type:Individual
Prefix:
First Name:ALEXIS
Middle Name:PAMALA
Last Name:TUCKER
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2185
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638
Mailing Address - Country:US
Mailing Address - Phone:541-409-3039
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 2185
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638
Practice Address - Country:US
Practice Address - Phone:541-409-3039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDAT-8582255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer