Healthcare Provider Details

I. General information

NPI: 1952095556
Provider Name (Legal Business Name): JERRY LAN TUCKER RDN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 06/06/2023
Certification Date: 06/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 DR MARTIN LUTHER KING JR AVE NE STE 102
ALBUQUERQUE NM
87102-3666
US

IV. Provider business mailing address

8201 GOLF COURSE RD NW STE 183
ALBUQUERQUE NM
87120-5842
US

V. Phone/Fax

Practice location:
  • Phone: 505-727-3028
  • Fax:
Mailing address:
  • Phone: 917-334-2823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License NumberLD2023084
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: