Provider Demographics
NPI:1578507034
Name:TUCKER, ANGELA J (PA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:J
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-2808
Mailing Address - Country:US
Mailing Address - Phone:936-760-7839
Mailing Address - Fax:936-756-1471
Practice Address - Street 1:508 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-2808
Practice Address - Country:US
Practice Address - Phone:936-760-7839
Practice Address - Fax:936-756-1471
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02970363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00019333Medicare PIN
TXP87875Medicare UPIN
TX8A6357Medicare PIN