Provider Demographics
NPI:1891407144
Name:TUCKER, BRAD
Entity Type:Individual
Prefix:MR
First Name:BRAD
Middle Name:
Last Name:TUCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7025 BERACASA WAY STE 202A
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3459
Mailing Address - Country:US
Mailing Address - Phone:561-765-7960
Mailing Address - Fax:
Practice Address - Street 1:7025 BERACASA WAY STE 202A
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3459
Practice Address - Country:US
Practice Address - Phone:561-765-7960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL30212454OtherFLORIDA NURSE REGISTRY LICENSE