Provider Demographics
NPI:1891426599
Name:TUCKER, BROCK
Entity Type:Individual
Prefix:MR
First Name:BROCK
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 1:1234 LATOUCHE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-4786
Mailing Address - Country:US
Mailing Address - Phone:952-388-9766
Mailing Address - Fax:
Practice Address - Street 1:1131 E INTERNATIONAL AIRPORT RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99518-1408
Practice Address - Country:US
Practice Address - Phone:907-276-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program