Healthcare Provider Details

I. General information

NPI: 1528394806
Provider Name (Legal Business Name): ACCOMMODATING MEDICAL PROVIDERS OF TEXAS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2009
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3008 BAYSIDE DR
ROCKWALL TX
75087-5307
US

IV. Provider business mailing address

3008 BAYSIDE DR
ROCKWALL TX
75087-5307
US

V. Phone/Fax

Practice location:
  • Phone: 469-951-9984
  • Fax:
Mailing address:
  • Phone: 469-951-9984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02092
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA02092
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberPA02092
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberPA02092
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberPA02092
License Number StateTX

VIII. Authorized Official

Name: MECHIELL DEMETRIUS TUCKER
Title or Position: OWNER
Credential: PA
Phone: 469-951-9984