Provider Demographics
NPI:1093802696
Name:PHIRI- TUCKER, RITA M (MD)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:M
Last Name:PHIRI- TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 S WILLIAMSON AVE
Mailing Address - Street 2:
Mailing Address - City:ELON
Mailing Address - State:NC
Mailing Address - Zip Code:27244-9280
Mailing Address - Country:US
Mailing Address - Phone:336-538-2416
Mailing Address - Fax:336-538-2395
Practice Address - Street 1:908 S WILLIAMSON AVE
Practice Address - Street 2:
Practice Address - City:ELON
Practice Address - State:NC
Practice Address - Zip Code:27244-9280
Practice Address - Country:US
Practice Address - Phone:336-538-2416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2022-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-01429208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908532Medicaid
NC5908532Medicaid