Provider Demographics
NPI:1659388759
Name:TUCKER, KATHLEEN L (MD)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:L
Last Name:TUCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:L
Other - Last Name:TUCKER-BIRD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-292-6100
Mailing Address - Fax:
Practice Address - Street 1:9493 S 700 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-3459
Practice Address - Country:US
Practice Address - Phone:801-576-0176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT831698521205207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000057479Medicare PIN
UT005587630Medicare PIN
UT006985028Medicare PIN
UT005806014Medicare PIN
UT005586731Medicare PIN
UT005583343Medicare PIN
UT005569155Medicare PIN
UT005548811Medicare PIN