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General NPI Number Information
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NPI Number | 1861751349
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Entity Type | Individual
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Provider Name | MALLORY PAIGE TUCKER PA-C
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Gender | Female
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Dates
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Enumeration Date | 05/03/2012
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Last Update Date | 06/14/2022
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Provider Practice Location Address
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Address Line | 1401 CENTERVILLE RD STE G02
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City | TALLAHASSEE
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State | FL
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Zip | 32308-4638
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Country | US
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Telephone | 850-431-2100
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Fax | 850-431-2199
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Provider Business Mailing Address
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Address Line | 1401 CENTERVILLE RD STE G02
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City | TALLAHASSEE
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State | FL
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Zip | 32308-4638
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Country | US
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Telephone | 850-431-2100
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Fax | 850-431-2199
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA9106576
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License Number State | FL
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