Provider Demographics
NPI:1790308260
Name:TUCKETT, BRADLEY DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:DAVID
Last Name:TUCKETT
Suffix:
Gender:M
Credentials:PA-C
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Other - First Name:
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Mailing Address - Street 1:4403 HARRISON BLVD STE 4400
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3290
Mailing Address - Country:US
Mailing Address - Phone:801-387-4550
Mailing Address - Fax:801-387-4565
Practice Address - Street 1:245 E HUDSON DR
Practice Address - Street 2:
Practice Address - City:ELK RIDGE
Practice Address - State:UT
Practice Address - Zip Code:84651-9506
Practice Address - Country:US
Practice Address - Phone:801-669-4297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2022-12-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT8818148-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant