Provider Demographics
NPI:1801818067
Name:TUCK, JEFFREY A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:A
Last Name:TUCK
Suffix:
Gender:M
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 1:750 W HIGH ST
Mailing Address - Street 2:SUITE 390
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45801-2969
Mailing Address - Country:US
Mailing Address - Phone:419-222-8432
Mailing Address - Fax:419-222-9057
Practice Address - Street 1:750 W HIGH ST
Practice Address - Street 2:SUITE 390
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-2969
Practice Address - Country:US
Practice Address - Phone:419-222-8432
Practice Address - Fax:419-222-9057
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH668363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHY31035Medicare UPIN
OHS66082Medicare UPIN
OHIG9352001Medicare ID - Type UnspecifiedGROUP NUMBER
OHTUPA12722Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER