=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730269861
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GORDON TUCKER RISK M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2006
-----------------------------------------------------
Last Update Date | 07/13/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8340 MISSION RD SUITE 210
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66206-1362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-642-0100
-----------------------------------------------------
Fax | 913-642-0176
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8340 MISSION RD SUITE 210
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66206-1355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-642-0100
-----------------------------------------------------
Fax | 913-642-0176
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 04-17341
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------