Healthcare Provider Details

I. General information

NPI: 1093367013
Provider Name (Legal Business Name): JASON MARK TUCKER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MERCY DR STE 100
MUSKEGON MI
49444-1833
US

IV. Provider business mailing address

6441 PINE VALLEY RD
CLARKSTON MI
48346-2231
US

V. Phone/Fax

Practice location:
  • Phone: 231-733-1326
  • Fax:
Mailing address:
  • Phone: 248-202-3069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010459
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: