Healthcare Provider Details

I. General information

NPI: 1316040850
Provider Name (Legal Business Name): ROBERT L TUCKER FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 04/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2372 HWY 49 EAST
SUMNER MS
38957-0250
US

IV. Provider business mailing address

PO BOX 627
WEBB MS
38966-0627
US

V. Phone/Fax

Practice location:
  • Phone: 662-375-9310
  • Fax:
Mailing address:
  • Phone: 662-375-9310
  • Fax: 662-375-9311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR853452
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: