Provider Demographics
NPI:1710951595
Name:TUCKER, ROBERT W (PA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:TUCKER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 QUARTERMAN STREET
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-3547
Mailing Address - Country:US
Mailing Address - Phone:912-287-0301
Mailing Address - Fax:912-287-1568
Practice Address - Street 1:218 QUARTERMAN STREET
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-3547
Practice Address - Country:US
Practice Address - Phone:912-287-0301
Practice Address - Fax:912-287-1568
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA002765207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002789BMedicaid
GA100002789CMedicaid
GA100002789BMedicaid
GA100002789CMedicaid