Provider Demographics
NPI:1629440243
Name:RUCKER, ALAN (RN)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:RUCKER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203-11 42ND AVE. #1A
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1869
Mailing Address - Country:US
Mailing Address - Phone:646-388-1459
Mailing Address - Fax:
Practice Address - Street 1:203-11 42ND AVE. #1A
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1869
Practice Address - Country:US
Practice Address - Phone:646-388-1459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA169338146L00000X
NY705674-1163W00000X
PARN677278163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic