Healthcare Provider Details

I. General information

NPI: 1235447152
Provider Name (Legal Business Name): PAUL NORMAN TUCKER MS, LADAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 04/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 MONTGOMERY BLVD NE BLDG 5
ALBUQUERQUE NM
87111-2468
US

IV. Provider business mailing address

9201 MONTGOMERY BLVD NE BLDG 5
ALBUQUERQUE NM
87111-2468
US

V. Phone/Fax

Practice location:
  • Phone: 505-217-1717
  • Fax: 505-213-0041
Mailing address:
  • Phone: 505-217-1717
  • Fax: 505-213-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4416
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: