1902892243 NPI number — LAURA A TUCKER NP

Table of content: LAURA A TUCKER NP (NPI 1902892243)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902892243 NPI number — LAURA A TUCKER NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
LAURA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALLIET
Provider Other First Name:
LAURA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902892243
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
THE NEUROSCIENCE GROUP OF NE WI
Provider Second Line Business Mailing Address:
WEST PAVILION 2ND FLOOR, 130 SENCOND STREET
Provider Business Mailing Address City Name:
NEENAH
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54956-2753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-725-9373
Provider Business Mailing Address Fax Number:
920-720-7392

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WEST PAVILION 2 FLOOR
Provider Second Line Business Practice Location Address:
130 SECOND STREET
Provider Business Practice Location Address City Name:
NEENAH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54956-2753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-725-9373
Provider Business Practice Location Address Fax Number:
920-720-7392
Provider Enumeration Date:
09/22/2005

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:  2582033 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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