Provider Demographics
NPI:1992790455
Name:VEGA-TUCKER, ELISSA V (MPT)
Entity type:Individual
Prefix:
First Name:ELISSA
Middle Name:V
Last Name:VEGA-TUCKER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:ELISSA
Other - Middle Name:
Other - Last Name:PARKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:75 BEEKMAN ST
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1438
Mailing Address - Country:US
Mailing Address - Phone:518-561-2000
Mailing Address - Fax:
Practice Address - Street 1:75 BEEKMAN ST
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901-1438
Practice Address - Country:US
Practice Address - Phone:518-561-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025861225100000X, 2251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02528696Medicaid
NYRA1839Medicare ID - Type Unspecified
NYQ16394Medicare UPIN