1316040850 NPI number — MR. ROBERT L TUCKER FNP

Table of content: MR. ROBERT L TUCKER FNP (NPI 1316040850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316040850 NPI number — MR. ROBERT L TUCKER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
ROBERT
Provider Middle Name:
L
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316040850
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 627
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEBB
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38966-0627
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-375-9310
Provider Business Mailing Address Fax Number:
662-375-9311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2372 HWY 49 EAST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMNER
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38957-0250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-375-9310
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  R853452 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 224548 . This is a "HEALTH PARTNERS CLAIMS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 00123085 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 253408 . This is a "MEDICARE PART A" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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