Healthcare Provider Details

I. General information

NPI: 1578507034
Provider Name (Legal Business Name): ANGELA J TUCKER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 MEDICAL CENTER BLVD
CONROE TX
77304-2808
US

IV. Provider business mailing address

508 MEDICAL CENTER BLVD
CONROE TX
77304-2808
US

V. Phone/Fax

Practice location:
  • Phone: 936-760-7839
  • Fax: 936-756-1471
Mailing address:
  • Phone: 936-760-7839
  • Fax: 936-756-1471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA02970
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: