Provider Demographics
NPI:1568568558
Name:TUCKER, PAMELA ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:ANN
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:ANN
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:6317 LAVANO DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76134-2828
Mailing Address - Country:US
Mailing Address - Phone:817-551-0806
Mailing Address - Fax:
Practice Address - Street 1:6080 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:BENBROOK
Practice Address - State:TX
Practice Address - Zip Code:76109-3912
Practice Address - Country:US
Practice Address - Phone:817-731-9331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1043859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T6758OtherBLUE CROSS BLUE SHIELD TX
TX8J4405Medicare UPIN
TXP00674010Medicare PIN