Healthcare Provider Details

I. General information

NPI: 1760090732
Provider Name (Legal Business Name): CHAD TUCKER FAMILY NURSE PRACTIT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2020
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

2700 QUARRY LAKE DR STE 300
BALTIMORE MD
21209-3746
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-9595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR247698
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: