Provider Demographics
NPI:1578160214
Name:TUCKER, LANDRY ROSS (PA-C)
Entity Type:Individual
Prefix:
First Name:LANDRY
Middle Name:ROSS
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 BLUEBONNET TRL
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013-5004
Mailing Address - Country:US
Mailing Address - Phone:817-709-4052
Mailing Address - Fax:
Practice Address - Street 1:901 W BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-6903
Practice Address - Country:US
Practice Address - Phone:512-447-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA14086363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant