Provider Demographics
NPI:1659365427
Name:TUCKER, TAMMY JEAN HALE (DO)
Entity Type:Individual
Prefix:DR
First Name:TAMMY
Middle Name:JEAN HALE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SOMERSET
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4091
Mailing Address - Country:US
Mailing Address - Phone:870-405-8579
Mailing Address - Fax:
Practice Address - Street 1:2905 S WALTON BLVD
Practice Address - Street 2:STE 17
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6730
Practice Address - Country:US
Practice Address - Phone:479-657-6800
Practice Address - Fax:479-268-4272
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150124003Medicaid
H58690Medicare UPIN
AR150124003Medicaid