Healthcare Provider Details

I. General information

NPI: 1609701929
Provider Name (Legal Business Name): TUCKER MENDONCA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 HENRY TECKLENBURG DR
CHARLESTON SC
29414-7710
US

IV. Provider business mailing address

33 DAVIS ST
SOUTH DARTMOUTH MA
02748-2311
US

V. Phone/Fax

Practice location:
  • Phone: 843-577-6957
  • Fax:
Mailing address:
  • Phone: 207-228-4946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License NumberRN10002778
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: