1881748440 NPI number — MARY WALL TUCKER FNP

Table of content: MARY WALL TUCKER FNP (NPI 1881748440)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881748440 NPI number — MARY WALL TUCKER FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
MARY WALL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

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:
1881748440
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 360
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYLVA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28779-0360
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-339-6065
Provider Business Mailing Address Fax Number:
828-538-4441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 N KING ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSONVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28792-4349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-693-9199
Provider Business Practice Location Address Fax Number:
828-692-2487
Provider Enumeration Date:
01/22/2007

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: 363LF0000X , with the licence number:  72955 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NC4942C . This is a "MEDICARE PTAN(LFM)" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 154W2 . This is a "BCBS NC(LFM)" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1881748440 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: P02130832 . This is a "RAILROAD MEDICARE PTAN(LFM)" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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