Provider Demographics
NPI:1609553155
Name:TUCKER, BRIAN ANDREW (CRS)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ANDREW
Last Name:TUCKER
Suffix:
Gender:M
Credentials:CRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 BILOXI DR APT D
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2319
Mailing Address - Country:US
Mailing Address - Phone:405-384-0849
Mailing Address - Fax:
Practice Address - Street 1:1120 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-5300
Practice Address - Country:US
Practice Address - Phone:405-573-3812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X
OK318182171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No376K00000XNursing Service Related ProvidersNurse's Aide