Provider Demographics
NPI:1588017495
Name:RUCKER, MICHAEL T (DNP, CRNA)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:RUCKER
Suffix:
Gender:
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 E BERKSWELL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7207
Mailing Address - Country:US
Mailing Address - Phone:606-224-5864
Mailing Address - Fax:
Practice Address - Street 1:2080 CHILD ST DEPT 5000
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32214-2111
Practice Address - Country:US
Practice Address - Phone:904-542-7632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11024227367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered