Provider Demographics
NPI:1033549670
Name:LUCK, TINA FAYE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:FAYE
Last Name:LUCK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 GRANDVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-8145
Mailing Address - Country:US
Mailing Address - Phone:325-226-2462
Mailing Address - Fax:
Practice Address - Street 1:36 E TWOHIG AVE STE 1100
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903
Practice Address - Country:US
Practice Address - Phone:325-658-6524
Practice Address - Fax:325-658-8895
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP124485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily