Provider Demographics
NPI:1790163814
Name:TUCKER, MARY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:TUCKER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 S 48TH ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-1200
Mailing Address - Country:US
Mailing Address - Phone:402-483-8600
Mailing Address - Fax:402-483-8689
Practice Address - Street 1:1500 S 48TH ST.
Practice Address - Street 2:SUITE 800
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1200
Practice Address - Country:US
Practice Address - Phone:402-483-8600
Practice Address - Fax:402-483-8689
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant