Provider Demographics
NPI:1346277282
Name:TUCKER, NICOLE (RPAC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-368-4005
Mailing Address - Fax:585-225-2685
Practice Address - Street 1:2655 RIDGEWAY AVE STE 180
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4296
Practice Address - Country:US
Practice Address - Phone:585-368-4005
Practice Address - Fax:585-225-2685
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008831363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02507317Medicaid
NY02507317Medicaid
P69572Medicare UPIN
PA0008Medicare ID - Type Unspecified