Provider Demographics
NPI:1386036796
Name:TUCKER, MATTHEW KYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KYLE
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-564-4873
Mailing Address - Fax:
Practice Address - Street 1:760 HIGHLAND OAKS DR STE 200
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7114
Practice Address - Country:US
Practice Address - Phone:336-277-4380
Practice Address - Fax:336-659-0659
Is Sole Proprietor?:No
Enumeration Date:2015-02-21
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-05545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant