Provider Demographics
NPI:1780838458
Name:TUCKER, EDWARD S (LMP)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:S
Last Name:TUCKER
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6312 ROCHE HARBOR RD
Mailing Address - Street 2:UNIT E
Mailing Address - City:FRIDAY HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98250-6754
Mailing Address - Country:US
Mailing Address - Phone:360-378-8742
Mailing Address - Fax:360-378-8742
Practice Address - Street 1:6285 ROCHE HARBOR RD
Practice Address - Street 2:
Practice Address - City:FRIDAY HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98250-6951
Practice Address - Country:US
Practice Address - Phone:360-378-8742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00011145174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA75332OtherREGENCE BLUE SHIELD
WA0118566OtherDEPT. OF LABOR & INDUSTRIES