Provider Demographics
NPI:1699001982
Name:TUCKER, CRYSTAL GAILE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:GAILE
Last Name:TUCKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:GAILE
Other - Last Name:GREENWALT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3637 US HIGHWAY 259 N APT 801
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-7780
Mailing Address - Country:US
Mailing Address - Phone:870-814-1980
Mailing Address - Fax:
Practice Address - Street 1:3637 US HIGHWAY 259 N APT 801
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7780
Practice Address - Country:US
Practice Address - Phone:870-814-1980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-22
Last Update Date:2015-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN608141367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered