Healthcare Provider Details

I. General information

NPI: 1265336481
Provider Name (Legal Business Name): TUCKER BRYANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2026
Last Update Date: 10/03/2026
Certification Date: 10/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 W NC HIGHWAY 54 STE 113
DURHAM NC
27707-5597
US

IV. Provider business mailing address

1415 W NC HIGHWAY 54 STE 113
DURHAM NC
27707-5597
US

V. Phone/Fax

Practice location:
  • Phone: 910-420-9626
  • Fax:
Mailing address:
  • Phone: 910-420-9626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number17083
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: