1932693587 NPI number — KARL TUCKER APRN

Table of content: KARL TUCKER APRN (NPI 1932693587)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932693587 NPI number — KARL TUCKER APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TUCKER
Provider First Name:
KARL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1932693587
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
822 S 1040 W # 3B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PAYSON
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84651-4614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-609-2448
Provider Business Mailing Address Fax Number:
801-609-2447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 N OREM BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OREM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84057-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-609-2448
Provider Business Practice Location Address Fax Number:
801-609-2447
Provider Enumeration Date:
06/18/2018

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: 363LP0808X , with the licence number:  7327288-4405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3007365 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com