Provider Demographics
NPI:1730101783
Name:TUCKER, MECHIELL DEMETRIUS (PA)
Entity Type:Individual
Prefix:
First Name:MECHIELL
Middle Name:DEMETRIUS
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 BAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-5307
Mailing Address - Country:US
Mailing Address - Phone:469-951-9984
Mailing Address - Fax:
Practice Address - Street 1:111 EXECUTIVE WAY STE 102
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-2388
Practice Address - Country:US
Practice Address - Phone:469-941-4029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02092363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C6425Medicare ID - Type Unspecified
TX00868WMedicare PIN
TX8B7352Medicare ID - Type Unspecified
TXS59706Medicare UPIN
TXDF8616Medicare PIN
TX8C6642Medicare ID - Type Unspecified
TXDF8616Medicare PIN
TX8C6642Medicare ID - Type Unspecified