Provider Demographics
NPI:1164814281
Name:BRUCKER, MARTHA EDIE (AGPCNP - BC)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:EDIE
Last Name:BRUCKER
Suffix:
Gender:F
Credentials:AGPCNP - BC
Other - Prefix:
Other - First Name:M.
Other - Middle Name:EDIE
Other - Last Name:BRUCKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AGPCNP- BC
Mailing Address - Street 1:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-4673
Mailing Address - Fax:214-645-7016
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-4673
Practice Address - Fax:214-645-7016
Is Sole Proprietor?:No
Enumeration Date:2015-02-26
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007479363LA2200X
NC201338363LA2200X
TXAP131049363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1164814281Medicaid
SCNP3256Medicaid
NC1164814281Medicaid