Provider Demographics
NPI:1629198155
Name:TUCKER, MARTHA MAE
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:MAE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2322 S 87TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74129-3030
Mailing Address - Country:US
Mailing Address - Phone:918-633-5260
Mailing Address - Fax:918-517-3662
Practice Address - Street 1:2907 S 93RD EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-6827
Practice Address - Country:US
Practice Address - Phone:918-633-5260
Practice Address - Fax:918-517-3662
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor