Provider Demographics
NPI:1639441132
Name:TUCKER, JASON (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
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:CMR 402
Mailing Address - Street 2:LANDSTUHL REGIONAL MEDICAL CENTER
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-0000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:CMR 402
Practice Address - Street 2:LANDSTUHL REGIONAL MEDICAL CENTER
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-0000
Practice Address - Country:US
Practice Address - Phone:850-420-3215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-31
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant