MEDICARE: MECHIELL DEMETRIUS TUCKER PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA02092	TX

General Provider Information

NPI Number	:	1730101783
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MECHIELL DEMETRIUS TUCKER PA

Provider Business Mailing Address
First Line	:	3008 BAYSIDE DR
Second Line	:
City	:	ROCKWALL
State	:	TX
Zip	:	75087-5307
Country	:	US
Telephone Number	:	469-951-9984
Fax Number	:

Provider Business Practice Location Address
First Line	:	111 EXECUTIVE WAY STE 102
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115-2388
Country	:	US
Telephone Number	:	469-941-4029
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/15/2020

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