Provider Demographics
NPI:1508574716
Name:TUCKER, LAUREN (PA)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:
Other - Last Name:HOENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:105 ARDMORE RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-1303
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 ARDMORE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-1303
Practice Address - Country:US
Practice Address - Phone:937-244-0412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2023-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.007991363A00000X
390200000X
OH50.007991RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program